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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8679 | 8679 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 279 | D | 0 | 1 | C5CK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a comprehensive care plan for one (1) of twenty-six (26) sampled residents. This resident was receiving an anti-anxiety medication on a regular basis; however, the resident's care plan made no mention of the anxious behaviors. Resident identifier: Resident #72. Facility census 38. Findings include: a) Resident #72 When reviewed on 07/18/12, the medical record of Resident #72 revealed the resident had received [MEDICATION NAME] 1 mg PO (by mouth) every morning for anxiety. The resident's care plan was reviewed and it included no mention of anxious behaviors. Employee #22, a facility nurse, was interviewed on 07/23/12 at 2:30 p.m., and confirmed there was no care plan for anxious behaviors. | 2016-04-01 |
| 8680 | 8680 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 323 | E | 0 | 1 | C5CK11 | Based on observation, review of labels on items in the store room, and staff interview, the facility failed to ensure the environment remained as free of accident and hazards as possible by allowing the doors to the supply room to remain unlocked. In the supply room were chemicals and supplies that could cause harm to residents. This practice had the potential to affect more than a minimal number of residents who were mobile. Facility census: 38. Findings include: a) During a random tour of the unit, on 07/17/12 at 10:25 a.m., a room labeled Supply Room was observed unlocked. This room had doors on each side leading into separate hallways. Each door was outfitted with a lock which required a key for entry, but both doors were unlocked at the time of this observation. Upon entering the room, many potentially hazardous items were observed, including disposable razors and items which had warning labels which stated, Contact medical care immediately or contact poison control center. These items were observed in the room and/or on a cart. These included, but were not limited to: - Pain relieving rub ointment - SSD 1% Silver Sulfadiazine Cream - Granulex Spray - Hydrogen Peroxide - Razors - Shaving Cream Employee #22, a facility nurse, was interviewed on 07/17/12 at 10:48 a.m., and the director of nursing (Employee #7) was interviewed on 07/17/12 at 11:20 a.m. Both confirmed the doors had locks that used keys and were unlocked, as well as the items in the room and cart were accessible to residents that were mobile. | 2016-04-01 |
| 8681 | 8681 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 329 | E | 0 | 1 | C5CK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and observations, the facility failed to ensure the medication regimens for four (4) of twenty-six (26) sampled residents were free from unnecessary medications. Resident #71 received anti-anxiety medication with no evidence of anxious behavior. Resident #14 remained on an antipsychotic medication without evidence of an attempted dose reduction. Resident #31 was receiving medication for [DIAGNOSES REDACTED]. Resident #72 was receiving an anti-anxiety medication with no evidence of anxiety. Resident identifiers: #71, #14, #31, and #72. Facility census: 38. Findings include: a) Resident #71 When reviewed on 07/16/12, the medical record revealed a physician's orders [REDACTED]. Further review divulged staff were administering the medication every day and sometimes twice daily. At the time this medication was administered, there was no evidence of associated behaviors to justify the need. Also, there was no evidence non-pharmacological interventions had been attempted to relieve any anxiety the resident was experiencing prior to the use of medication. When interviewed, on 07/18/12 at 2:42 p.m., Employee # 22 (Nurse) was asked to provide evidence of the need for the anti-anxiety medication. This employee confirmed there was no anxiety documented for this resident, and no monitoring of behaviors. b) Resident #14 Review of the medical record on 07/16/12, found Resident #14 had been receiving the antipsychotic [MEDICATION NAME] since 08/11/11. Further review of the medical record found no evidence the facility had attempted a gradual dose reduction. According to the regulation, the drug regimen of each resident must be reviewed at least once a month. No evidence was found to indicate a review and recommendation for this medication had been completed for Resident #14. On 07/19/12, at approximately 8:58 a.m., Employee #7 (DON) provided a copy of consultation provided by the pharmacist that was completed … | 2016-04-01 |
| 8682 | 8682 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 371 | F | 0 | 1 | C5CK11 | Based on observation and staff interview, the facility failed to properly store food items in the resident's pantry area and failed to served items from the kitchen in a sanitary manner. Food items were found in the residents' refrigerator open and not dated. Additionally, the refrigerator in the pantry where residents' items were kept was unclean. Food items were also served from the kitchen to the unit with no covering over the dessert. This had the potential to affect more than an isolated number of residents. Facility census: 38. a) Resident pantry area. Observation of the resident pantry was conducted with Employee #7 (the director of nursing) on 07/19/12, at approximately 8:30 a.m. Food items were found open and contained no date. A carton of milk was open with no date, a jar of pumpkin butter contained no date, a bottle of salad dressing was open and was not dated, one container of cucumbers with vinegar was observed with no resident's name and contained no date. Employee #7 (DON) immediately disposed of the undated food items, and confirmed the items should have been labeled and dated. b) Observation of the residents' pantry, on 07/19/12, found the refrigerator to be unclean and crusty food was adhered to the shelving in the refrigerator. Employee #7 (the director of nursing) was present during the observation. She immediately called housekeeping to clean the refrigerator. According to the facility's policy and procedure for cleaning the refrigerator, the area was to be cleaned once a week. On 07/19/12, at approximately 8:30 a.m., Employee #7 (DON) confirmed the refrigerator needed to be cleaned. b) Kitchen observations Observation of the kitchen area, on 07/17/12 at 11:40 a.m., revealed the dietary department did not store and serve items in a sanitary manner as evidenced by small bowls containing pears and some containing gelatin were observed on trays near the tray line as the meal service was about to begin and were not covered. Once tray service was complete, the cart was followed to the second floor… | 2016-04-01 |
| 8683 | 8683 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 428 | D | 0 | 1 | C5CK11 | Based on record review and staff interview, the pharmacist failed to identify and address the need for a dose reduction for one (1) of twenty-six (26) residents on the sample. Resident identifier: #14. Facility census: 38. Findings include: a) Resident #14 Review of the medical record on 07/16/12, found Resident #14 had been receiving the antipsychotic Seroquel since 08/11/11. Further review of the medical record found no evidence the pharmacisit had recommended a gradual dose reduction be attempted. According to regulation the drug regimen of each resident must be reviewed at least once a month. No evidence was found to indicate this had been completed for Resident #14. On 07/19/12 at approximately 8:58 a.m., Employee #7 provided a copy of consultation provided by the pharmacist that was completed 07/18/12. The director of nursing confirmed she could find no evidence the Seroquel had been reviewed before this time. . | 2016-04-01 |
| 8684 | 8684 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 431 | D | 0 | 1 | C5CK11 | Based on observation and staff interview, the facility failed to dispose of expired medications. The facility had two (2) bottles of expired medications in the medication storage room available for use. This practice had the potential to affect more than an isolated number of residents. Facility census: 38. Findings include: a) Observation of the medication storage room with Employee #7 (director of nursing), on 07/19/12, at approximately 8:45 a.m., found a bottle of Fortical nasal spray with an expiration date of 05/12/12. Further observation found Brovana Inhalant solution with an expiration date of 04/12/12. Employee #7 (DON) immediately disposed of the expired medications. . | 2016-04-01 |
| 8685 | 8685 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2012-07-24 | 441 | E | 0 | 1 | C5CK11 | Based on staff interview and review of the facility's policy and procedure for tracking infections, the facility failed to implement an effective infection control program to identify infections and prevent their spread to other residents. The facility's policy and procedure identified no plan for tracking and trending infections and prevention of the spread of infections. This had the potential to affect more than an isolated number of residents. Facility census: 38. Findings include: a) Infection control policy and procedure Review of the infection control policy and procedure found it did not describe a means of tracking and trending infections. On 07/23/12, at approximately 3:35 p.m., Employee #31 (infection control nurse) provided a copy of a resident order list containing a list of antibiotics ordered for residents. She confirmed she had no forms which included the resident room number, the antibiotic and the exact type of infection the resident had. Employee #31 also provided a quarterly list which contained the number of urinary tract infections for the quarter, the number of upper respiratory infections. The list provided failed to list the resident, the room number, and the type of infection. She was asked if she had anything on a monthly basis to identify infections. She stated, this is all I have. On 07/24/12, at approximately 1:15 p.m., Employee #31 confirmed she had no other information related to infections. No evidence could be found the facility had developed a method for tracking and trending infections in order to identify whether infections were being spread, and, if indicated, to develop interventions to prevent the spread of infections. The facility failed to develop a policy on how they were going to monitor and track infections. | 2016-04-01 |
| 10301 | 10301 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 329 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents, to assure their drug regimen was free of unnecessary drugs including drugs without adequate monitoring. One (1) resident was receiving an antipsychotic medication for behaviors with no evidence those behaviors continued to be present. One (1) resident was receiving a medication for lowering cholesterol levels without evidence of recommended lab studies to assure their safety. Resident identifiers: #34 and #31. Facility census: 34. Findings include: a) Resident #34 When reviewed on 05/05/10, the resident's medical record disclosed he was receiving [MEDICATION NAME] 50 mg two (2) times daily for agitation. The resident had been receiving the medication since 07/29/09. When reviewed for behaviors associated with the agitation, documentation suggested the resident became agitated when staff attempted to persuade him to shower. The record disclosed nurses' notes on only two (2) occasions, 02/10/10 and 03/02/10, both associated with attempts to bath resident. The resident's behavior monitoring sheets for February 2010 through April 2010 disclosed agitated behaviors on three (3) occasions in March 2010. The resident's care plan, when reviewed, disclosed the following problem statement identified by staff on 05/12/09: "Behavior problem related to verbally abusive behavior as evidenced by verbally abusive." On 02/03/10, the care plan problem stated, "D/C (discontinue) no behavior issues for some time now." A pharmacy recommendation, dated 12/23/09, requested the resident's attending physician attempt a gradual dose reduction of the medication. The physician stated "no change" and did not decrease the medication. The physician declined an additional request for a gradual dose reduction attempt on 04/15/10, with no explanation given. These findings were brought to the attention of the vice president of nursing services (Employee #… | 2015-05-01 |
| 10302 | 10302 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 274 | D | 0 | 1 | MM9U11 | . Based on medical record review and staff interview, the facility failed to complete a comprehensive assessment when a significant change in status occurred for one (1) of twenty-one (21) Stage II sample residents. This resident had significant declines in both mood state and self-performance of bathing, but a significant change in status assessment was not completed. Resident identifier: #53. Facility census: 34. Findings include: a) Resident #53 Review of this resident's medical record, and interview with the social worker (Employee #30) on 05/12/10 at 10:20 a.m., revealed this resident had experienced declines in mood indicators and activities of daily living (ADL) self-performance since admission on 12/12/09. Comparison of the resident's comprehensive admission assessment (with an assessment reference date (ARD) of 12/22/09) and her first abbreviated quarterly assessment (with an ARD of 03/24/10) revealed the following: - Resident #53 only had one (1) indicator of depression, anxiety, and/or sad mood present on admission (coded at Item E.1.m.). However, on her quarterly assessment completed three (3) months later, the assessor noted the presence of six (6) indicators of depression, anxiety, and/or sad mood (coded at Items E1.a., E1.c, E1.d, E1.h, E1.i, and E1.n.). - In Section G, physical functioning and structural problems, the resident exhibited a significant decline in self-performance of bathing from "2" (physical help limited to transfer only) on admission to "4" (total dependence) three (3) months later. This significant decline in status was not identified when the quarterly assessment was reviewed and signed by the interdisciplinary team on 03/25/10. No comprehensive assessment was completed in recognition of this significant change in status as of 05/12/10. On 05/12/10 at 10:40 a.m., this information was brought to the attention of the assessment coordinator (Employee #25). At that time, Employee #25 confirmed the changes and confirmed that a comprehensive assessment had not been completed as requir… | 2015-05-01 |
| 10303 | 10303 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 431 | B | 0 | 1 | MM9U11 | . Based on observation and staff interview, the facility failed to assure the safe storage of drugs and biologicals, by retaining a vial of immunization past the manufacturer's expiration date and storing it in a refrigeration rather than in the freezer as recommended. This practice had the potential to affect any resident with orders for this medication. Facility census: 34. Findings include: a) On 05/11/10 at 9:20 a.m., observation of the facility's medication storage room, including the medication storage refrigerator used to store all medications requiring refrigeration for facility residents, found a boxed ampul with a label reading "Varicella Virus Vaccine". The labeled box also stated the medication should be stored at an average temperature of 5 degrees Fahrenheit (F), and the noted expiration date of the medication was 19 March 2010. The refrigerator temperature at that time was 46 degrees F. Two (2) licensed practical nurses (LPNs - Employees #21 and #22) were present at the time ,and although neither of the nurses had any idea why the medication was there or who it was for, they both confirmed the medication was beyond the expiration date and was not stored as recommended on the label. . | 2015-05-01 |
| 10304 | 10304 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 492 | C | 0 | 1 | MM9U11 | . Based on record review and staff interview, the facility failed to provide the opportunity to request a demand bill for residents who were discontinued from Medicare-covered skilled services, as required to comply with 42CFR489.21(b). This practice affected all residents who were discontinued from Medicare-covered skilled services. Facility census: 34. Findings include: a) Review of the information provided residents who were discontinued from Medicare-covered skilled services, with the social worker (SW - Employee #30) on 05/11/10, revealed the facility was not providing the residents or their responsible parties an opportunity to request a demand bill when skilled services were discontinued. At that time, the SW provided copies of the letters sent, which did not include the information required to request a demand bill. He was unaware of any other forms required, and the facility had not been providing these notices to applicable Medicare residents. Therefore, no resident was offered the opportunity to request a demand bill. . | 2015-05-01 |
| 10305 | 10305 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 364 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to assure pureed foods were attractive when served. The pureed food items flattened out and ran together on the plates. In addition, garnishes were not provided residents who were ordered pureed diets. This practice affected each of the eight (8) residents who had a physician's orders [REDACTED]. Findings include: a) On 05/11/10 at 12:05 p.m., observation was made of food service in the kitchen. Pureed beef, pureed noodles, and pureed green beans were served the residents requiring pureed diets. All these products were thin and without form. They flattened and ran together on the plates, creating an unattractive and unappetizing presentation. At the time of the observation, the thin pureed foods were brought to the attention of Employee #90, the dietary manager (DM). The DM confirmed the pureed foods should have a shape / form and the pureed foods served at the meal did not, making the meal unattractive. Additionally, garnishes (to add interest and contrast to the meal) were used at this meal for residents who were not ordered pureed foods; however, garnishes were not provided residents who required pureed foods. . | 2015-05-01 |
| 10306 | 10306 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 371 | F | 0 | 1 | MM9U11 | . Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which had the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) On 05/11/10 at 11:50 a.m., soup bowls and water pitchers were observed stacked inside each other. They contained moisture, creating a medium for bacterial growth. At this time, the situation was brought to the attention of the dietary manager (DM). The DM confirmed the bowls and pitchers should have been air dried prior to stacking inside each other b) Observation, at 11:50 a.m. on 05/11/10, also revealed the inside finish was worn off several plastic soup bowls. Once the finish is gone, these food service items cannot be effectively sanitized. . | 2015-05-01 |
| 10307 | 10307 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 309 | D | 0 | 1 | MM9U11 | **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 attain or maintain the highest practicable physical well-being for two (2) of twenty-one (21) Stage II sample residents. One (1) resident had no follow-up assessments or monitoring after two (2) falls, and another resident's ill-fitting socks were causing indentations in the resident's lower legs. Resident identifiers: #31 and #12. Facility census: 34. Findings include: a) Resident #31 Medical record review, on 05/12/10, revealed this resident fell on [DATE], and was taken to the emergency room (ER) for evaluation. The next note, also on 03/08/10, described the resident being brought back from the ER and the resident's current condition. There were no nursing notes, between 03/08/10 and 03/15/10, seven (7) days later. The note on 03/15/10 did not mention the fall. There was no evidence the facility did any type of follow-up assessment or monitoring of the resident after the fall on 03/08/10. This resident fell again on 04/29/10 at 1930 (7:30 p.m.) and was taken to the ER. According to the medical record, the resident returned to the facility at 2200 (8:36 p.m.). There were no nursing notes regarding the fall and no evidence of any assessment or monitoring for the next three (3) days, until 05/02/10 at 1240 (12:40 p.m.). Interview with the vice president of patient care services (Employee #32), at 9:45 a.m. on 05/13/10, revealed nursing staff were supposed to complete follow-up assessments after any fall. Employee #32 reviewed the medical record and was unable to find any assessments following the fall on 03/08/10. Additionally, Employee #32 confirmed there should have been follow-ups between 04/29/10 and 05/02/10. -- b) Resident #12 At 2:00 p.m. on 05/12/10, during an interview with this resident, observation revealed the elastic tops of both of the resident's socks were making indentations in her legs just abo… | 2015-05-01 |
| 10308 | 10308 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 411 | D | 0 | 1 | MM9U11 | . Based on observation, resident interview, and staff interview, the facility failed to obtain needed dental services for one (1) of twenty-one (21) Stage II sample residents. The facility had identified the resident's teeth were in poor condition and that she needed dental care; however, this service had not been obtained or pursued by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to "Coordinate arrangements for dental care..." As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the res… | 2015-05-01 |
| 10309 | 10309 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 282 | D | 0 | 1 | MM9U11 | . Based on medical record review, resident interview, observation, and staff interview, the facility failed to implement a care plan for one (1) of twenty-one (21) Stage II sample residents. This resident had a care plan related to broken teeth and dental caries which was not implemented by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to "Coordinate arrangements for dental care..." As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the resident. . | 2015-05-01 |
| 10310 | 10310 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 311 | E | 0 | 1 | MM9U11 | . Based on observations and staff interview, the facility failed to assure six (6) of thirty-four (34) residents, identified through random observations, were provided services to assure maintenance or improvement of their ability to feed themselves. Resident identifiers: #67, #14, #2, #29, #53, and #13. Facility census: 34. Findings include: a) Residents #14, #13, #2, and #67 Observation of the evening meal was conducted beginning at 5:45 p.m. on 05/03/10. Ten (10) residents ate in their rooms that evening. These four (4) residents needed prompting and encouragement to eat their meals. No staff members were observed monitoring the hallways to provide necessary prompting and encouragement to these residents, who were not eating. The only time a staff member was observed on the hallway was at 6:17 p.m., when one (1) nursing assistant went to see if the residents were finished with their meals. 1. Resident #14 - At 6:00 p.m., this resident was asleep with her uneaten meal in front of her. She had eaten nothing. 2. Resident #13 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 3. Resident #2 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 4. Resident #67 - At 6:05 p.m., this resident had stopped eating and was just sitting quietly in her room. The meal was still in front of her. She had eaten approximately 10% of her meal. -- b) Resident #67 In addition to the evening meal observation on 05/03/10, this resident was observed during the evening meal at 6:00 p.m. on 05/12/10. The resident was asleep with her uneaten meal in front of her. At 6:05 p.m., the director of nursing (DON) was asked to observe this situation, and she did. At that time, the DON confirmed the resident required prompting and encouragement at meals. -- c) Observations were made in the dining room at the evening meal on 05/03/10 and at the noon meal on 05/04/10. Several residents were seated at tables which were so … | 2015-05-01 |
| 10311 | 10311 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 281 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure that services provided met current professional standards of quality, by administering the medication [MEDICATION NAME], to four (4) of ten (10) residents observed during medication administration, outside of the recommendations for use by the manufacturer of the medication. Resident identifiers: #3, #8, #6, and #15. Facility census: 34. Findings include: a) Residents #3 and #8 During medication administration by a licensed practical nurse (LPN - Employee #22) on 05/11/10 at 9:00 a.m. and 10:17 a.m. respectively, Residents #3 and #8 were observed receiving their medications. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: "Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach." b) Residents #6 and #15 During medication administration by Employee #22 on 05/12/10 at 9:00 a.m., Residents #6 and #15 were observed receiving their medication. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: "Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach." When interviewed on 05/12/10 at 11:00 a.m., another LPN (Employee #28) stated she had spoken to the unit's consulting pharmacist concerning this information the previous evening, and the pharmacist agreed with this information and stated she had planned to submit that recommendat… | 2015-05-01 |
| 10312 | 10312 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 272 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and resident interview, the facility failed, for three (3) of twenty-one (21) Stage II sample residents, to complete initial and/or periodic comprehensive assessments of each resident's functional capacity, to include assessments of skin condition, bladder continence, and nutritional status. Resident identifiers: #9, #31, and #53. Facility census: 34. Findings include: a) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he "came from hospital with them." When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders [REDACTED]. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, "Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse." Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to b… | 2015-05-01 |
| 10313 | 10313 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 279 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed, for seven (7) of twenty-one (21) Stage II sample residents, to develop a comprehensive plan of care that accurately described the services to be furnished to each resident to assist in attaining or maintaining the highest practicable physical, mental and/or psychosocial well being. Two (2) residents had no care plan related to the use of an indwelling Foley urinary catheter, one (1) resident had no care plan related to urinary incontinence, one (1) resident had no care plan for pressure ulcers, one (1) resident had no care plan for the restoration of bladder function, one (1) resident had no care plan for the need for a nutritional assessment, and one (1) resident had a care plan with inappropriate / unexplainable interventions. Resident identifiers: #32, #18, #33, #9, #31, #2, and #53. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior t… | 2015-05-01 |
| 10314 | 10314 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 428 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure that irregularities noted by the consulting pharmacist for two (2) residents reviewed were reported to a resident's attending physician, and failed to assure that reported irregularities for three (3) residents were acted upon by their attending physician within a reasonable time period. This practice affected five (5) of twenty-one (21) Stage II sample residents. Resident identifiers: #14, #32, #34, #31, and #53. Facility census was 34. Findings include: a) Resident #14 When reviewed on 05/11/10 at 4:00 p.m., the resident's medical record disclosed a "Chronological Record of Drug Regimen Review" form dated 03/24/10. The consultant registered pharmacist (RPH) made recommendation to the resident's attending physician and the unit's director of nurses (DON) relevant to an irregularity in the resident's drug regimen. This recommendation could not be found on the medical record. Facility staff was asked to locate the recommendation for surveyor review. On 05/12/10 at 11:55 a.m., a licensed practical nurse (LPN - Employee #28) confirmed the recommendation was not available and there was no evidence it had ever been reported to the DON or attending physician as stated. This employee contacted the RPH, and the report was faxed to the unit for review by the DON and attending physician at that time. -- b) Resident #32 When reviewed on 05/11/10, the resident's medical record disclosed a "Pharmacy to Physician communication" document dated 01/26/10, which recommended the physician consider changing a medication, Prilosec (used in the treatment of [REDACTED]. The resident had the medical [DIAGNOSES REDACTED]. This recommendation stated that Prilosec may decrease the effectiveness of another medication, Plavix (a medication used to help prevent harmful blood clots from forming, which given to people who have had a recent heart attack or stroke). Further review revealed the physici… | 2015-05-01 |
| 10315 | 10315 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 315 | G | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents who were continent of urine when they entered the facility and became incontinent, to assure timely and appropriate assessment in an effort to possibly regain urinary continence. This resulted in actual harm, as both residents stated a desire to regain normal bladder function and no attempts were made by the facility to assist them with this goal. Resident identifiers: #32 and #31. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded "0") with no devices or appliance (such as an indwelling catheter) present. A second admiss… | 2015-05-01 |
| 10316 | 10316 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 278 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and observation, the facility failed to assure the minimum data set (MDS) assessment accurately reflected the physical status of two (2) of twenty-one (21) Stage II sample residents. Resident identifier: #31 and #33. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., observation made as the resident spoke found broken and carious teeth. The resident described her teeth as being in "pretty bad shape" and opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. The resident's initial minimum data set (MDS), with an assessment reference date (ARD) of 02/07/10, was reviewed. Section L, relative to oral / dental status, did not accurately identify the condition of the resident's teeth. L.1.d "Broken loose, carious teeth" was not marked on the MDS, even though this condition had to have existed upon the resident's admission on 01/26/10. -- b) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 (a licensed practical nurse and the medical record coordinator) stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the Extended Care Unit (ECU) of the facility on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary… | 2015-05-01 |
| 10317 | 10317 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 363 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, menu review, recipe review, and staff interview, the facility failed to assure menus were followed for 1200 and 1500 calorie diets, and failed to assure there were menu plans for 2 gram sodium, cardiac, and renal diets. This practice affected fourteen (14) of thirty-three (33) residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) Observation of meal service, on 05/11/10 at 12:05 p.m., revealed all residents were served a 3 ounce portion of meat. Review of the menu plan for this meal revealed the three (3) residents requiring 1200 and 1500 calorie diets were supposed to be served a 2 ounce portion of meat at this meal. At 12:30 p.m., this was brought to the attention of the dietary manager (DM - Employee #90), who confirmed the menu called for 2 ounces, yet 3 ounces were served to these residents. b) Medical record review revealed there were seven (7) residents with a physician's orders [REDACTED]. Review of the menu plan, for the noon meal on 05/11/10, revealed there were no specific menu plans for 2 gram sodium, cardiac, and renal diets. The menu did not indicate which food items were to be salt-free and/or fat-free for these diets. When this was brought to the attention of the DM, the DM stated the specific directives for these diets were on the recipes. The recipes for this meal were reviewed with the DM. There were no special directives for 2 gram sodium, cardiac, or renal diets on the recipes. . | 2015-05-01 |
| 10318 | 10318 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 323 | G | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed, for one (1) of twenty-one (21) Stage II sample residents, to provide a resident environment as free of accident hazards as possible, by failing to ensure staff consistently secured and alarmed an exit door leading from the unit to a stairwell. This practice resulted in actual harm for Resident #30 when she exited the door unnoticed and fell down eight (8) steps in her wheelchair, sustaining an acromioclavicular joint separation (separated shoulder). Resident identifier: #30. Facility census: 34. Findings include: a) Resident #30 Review of the facility's incident / accident reports, on 05/11/10, revealed a report stating that, on 03/23/10 at 11:00 a.m., Resident #30 was found in a stairwell off the Extended Care Unit (ECU) at the bottom of eight (8) stairs. Further review of the document disclosed that, following investigation, it was determined a staff member had failed to utilize the proper method of securing the door and re-setting the door alarm after another resident had activated the alarm the day before. This information was confirmed in an interview with vice president of patient care services (Employee #32) on the morning of 05/13/10. The resident's medical record, when reviewed on 05/12/10, disclosed this [AGE] year old female was known to the facility to wander and to be at risk for falling. According to the resident's care plan, which was reviewed on 05/12/10, staff was aware the resident was a high risk for falls related to a history of falls. Interventions to assure the resident was free from falls included measures such as providing activities that minimize the potential for falls while providing diversion and distraction and applying a bed alarm and an EZ release seat belt while in wheelchair. The resident also wore a WanderGuard alarming device / bracelet, but this door was not equipped with the WanderGuard system. Review of the resident's minimum… | 2015-05-01 |
| 10605 | 10605 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 152 | E | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. "Determination of incapacity. "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..." - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the … | 2015-01-01 |
| 10606 | 10606 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 309 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide services and care for two (2) of eight (8) sampled residents. Resident #35 was in the facility for seven (7) days with no bowel movement before interventions were implemented for constipation. Resident #39 was noted by a nurse to have experienced a possible "change in condition", for which there was no description, no assessment, and no evidence of follow-up. Resident identifiers: #35 and #39. Facility census: 38. Findings include: a) Resident #35 Record review revealed Resident #35 was admitted on [DATE]. The bowel elimination record revealed no recorded bowel movements until 06/14/11. A small hard bowel movement was recorded on this date. Bowel movements were recorded daily through 06/20/11. From 06/21/11 through 06/24/11, the resident did not have a bowel movement. An order was obtained on 06/25/11 for milk of magnesia (MOM) 30 cc every three (3) days as needed (PRN) for constipation. On 06/25/11 and 06/26/11, there were eight (8) extra, extra large bowel movements recorded. There were no recorded bowel movements from 06/27/11 through 07/03/11, when the record revealed the resident had a large bowel movement. The Medication Administration Record [REDACTED]. On 09/29/11 at 2:32 p.m., an interview with the director of nursing (DON - Employee #169) and the vice president of patient care (Employee #134) revealed there was no formal protocol for staff to follow regarding constipation. Employee #134 stated, "It was understood, an order would be obtained for the resident to receive milk of magnesia every three days, if they had not had a bowel movement." This employee further agreed there was "a lack of consistency" in doing this. -- b) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible "COC" (change of condition). The note indicated the resident "seemed dazy". The situation was seriou… | 2015-01-01 |
| 10607 | 10607 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 329 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to assure the medication regimens of three (3) of eight (8) sampled residents were free from unnecessary medications. These residents were given medications without evidence of need, without attempts at non-pharmacological interventions, without adequate assessment of possible causes for changes in behavior, and/or without adequate monitoring. Resident identifiers: #9, #5, and #35. Facility census: 38. Findings include: a) Resident #5 Medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. She had been receiving [MEDICATION NAME] 100 mg at hs (bedtime) since 06/23/11. On 07/04/11, the dosage of [MEDICATION NAME] was doubled to 100 mg twice a day. Review of the resident's nursing notes, dated 07/01/11, revealed the resident was more agitated and was going to the bathroom more frequently. A urine culture and sensitivity was ordered on that date. On 07/02/11, the resident was ordered Bactrim DS twice daily for three (3) days, then Bactrim 80/400 mg daily "ongoing". (Bactrim is an antibiotic medication used frequently for a urinary tract infections [MEDICAL CONDITION].) On 07/04/11, nursing notes described the resident was "Very mobile while up in w/c (wheelchair). Goes from one door to another door setting off alarm. In constant motion & movement. Wanderguard system functioning well. Still on po (by mouth) antibiotic therapy ..." There was no evidence of attempts at redirection or other non-pharmacological interventions. Additionally, there was no evidence that possible causal factors for the behaviors had been assessed. On 07/04/11 at 20:00 (8:00 p.m.), a verbal order was received to increase the [MEDICATION NAME] from 100 mg daily to 200 mg daily. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed there was no evidence of need for this increased dosage of [MEDICATION N… | 2015-01-01 |
| 10608 | 10608 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 151 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The resident was walked to her room, all the while screaming "No, no… | 2015-01-01 |
| 10609 | 10609 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 222 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of eight (8) sampled residents had the right to be free from chemical restraints. This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The… | 2015-01-01 |
| 10610 | 10610 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 250 | D | 1 | 0 | 0VZD11 | . Based on medical record review and staff interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-bring for two (2) of eight (8) sampled residents. The facility failed to assure staff was knowledgeable regarding the provision of alternatives to drug therapy and/or chemical restraints. Additionally, there was no evidence staff understood why residents act as they do, what residents are attempting to communicate by their actions, and what individual needs the staff must meet for each resident. Resident identifiers: #41 and #5. Facility census: 38. Findings include: a) Resident #41 This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. There was no evidence staff were assisted in understanding this resident had a right to autonomy and self determination, so taking away these rights resulted in unacceptable behaviors, resulting in a chemical restraint. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/… | 2015-01-01 |
| 10611 | 10611 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 514 | D | 1 | 0 | 0VZD11 | . Based on medical record review and staff interview, the facility failed to assure the clinical record for one (1) of eight (8) sampled residents was complete. This resident was noted to have a change in condition. The documentation regarding this change in condition did not contain enough information to indicate staff knew the status of the resident. This documentation was needed to assure necessary care and services were provided the resident. Resident identifier: #39. Facility census: 38. Findings include: a) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible "COC" (change of condition). The note indicated the resident "seemed dazy". The situation was serious enough the nurse documented she believed the resident should be sent to the emergency room (ER). Vital signs were documented on the note dated 06/10/11 at 02:21 (2:21 a.m.). The note contained no documentation which described the COC. There were no further nursing notes until 06/13/11 at 04:49 (4:49 a.m.). The contents of this note were not related to the COC. Interview with the acting director of nursing (DON - Employee #171), at 10:15 a.m. on 09/30/11, confirmed COC meant "change of condition". Employee #171 also confirmed there was no description of the COC, which was necessary to assure the optimum provision of care and services for this resident. | 2015-01-01 |
| 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 | ||
| 9496 | 9496 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 161 | E | 0 | 1 | DLX411 | Based on a review of the facility's surety bond and staff interview, the facility failed to provide a surety bond in amount sufficient to assure the security of all personal funds of residents deposited with the facility. During a review of the surety bond, with an effective date of 05 August 2010 to 05 August 2011, it was discovered the bond was in the amount of three thousand ($3,000.00) dollars. During a review of the Resident Trust Trial Balance Report dated 05/01/2011 thru 06/22/2011, it was discovered the current ending balance was $3,245.43, which is above the amount of the surety bond. This practice fails to assure the security of all personal funds of residents deposited with the facility as required and has the potential to affect fourteen (14) residents who have deposited funds with this facility. Facility census:47. Findings include: a) Review of the facility's surety bond, with an effective date of 08/05/10 to 08/05/11, revealed the bond was in the amount of three thousand ($3,000.00) dollars. Review of the Resident Trust Trial Balance Report, dated 05/01/2011 thru 06/22/2011, found the current ending balance was $3,245.43, which exceeded the amount of the surety bond. An interview with the facility's office manager (Employee #55), on 06/22/11 at 10:50 a.m., confirmed the amount of the surety bond was not sufficient to cover the balance of the resident funds for the fourteen (14) residents who have deposited funds with the facility. | 2015-11-01 |
| 9497 | 9497 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 166 | D | 0 | 1 | DLX411 | Based on family interview, review of the facility's concern / complaint files, staff interview, observation, and a review of a resident's clothing list, the facility failed to provide prompt efforts to resolve grievances related to missing personal items for one (1) of twenty-seven (27) Stage II sample residents. Resident #18's family reported as missing items that were listed on the resident's clothing list. The items were not found, and the facility did not respond to the family member's concern. Facility census: 47. Findings include: a) Resident #18 Resident #18's family member, when interviewed on 06/16/11 at 3:39 p.m., related concerns about missing personal items. The missing items were two (2) gowns, a pair of house shoes, and a fleece blanket. The family member stated these items were marked with the resident's name, and she had talked with both laundry staff and the supervisor about them. The items had been missing for about a month. A review of the facility's complaint / concern files did not find any information about Resident #18's missing items. During an interview with the laundry supervisor (Employee #26) on 06/21/11 at 10:20 a.m., she stated Resident #18's family did not talk with her about any missing laundry. She stated the afternoon shift laundry person (Employee #39) did the resident's personal laundry, and she would have Employee #39 speak with this surveyor when Employee #39 came on duty that afternoon. In an interview during the late afternoon of 06/21/11, Employee #39 said she talked with Resident #18's daughter about two (2) weeks ago. She said she did find the gowns but not the house shoes and blanket. She did not notify the family she found the gowns. She said there was a bulletin board in the laundry where missing items are posted. This was observed with the employee, and information about Resident #18's missing items was not on the bulletin board. Employee #39 said the midnight shift laundry person may have removed it. At this time, the clothing and personal items located by the bulle… | 2015-11-01 |
| 9498 | 9498 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 225 | D | 0 | 1 | DLX411 | Based on resident interview, staff interview, and review of the facility's internal investigations into allegations of abuse / neglect, the facility failed to immediately report all allegations of abuse to State agencies as required by law for two (2) of twenty-seven (27) Stage II sample residents who reported allegations of verbal abuse by a nursing assistant. Resident identifiers: #47 and #15. Facility census: 47. Findings include: a) Residents #47 and #15 1. During an interview on 06/14/11 at 9:57 a.m., Resident #47 reported that a nursing employee screamed at her like she was a dog. She stated, I can't walk, and one night we got up and I couldn't walk. The woman that works with him is not up to par. He talked to me like a dog and told me I should just stay in the bed and keep my mouth shut. She said she did not tell anyone about this, as she did not feel it would do any good. An interview with social worker (Employee #8), on the mid-afternoon of 06/15/11, found she had not received any complaints by residents about being yelled at by staff. During an interview with the director of nursing (DON) at 3:00 p.m. on 06/15/11, she said she had investigated a nursing assistant (Employee #52) for yelling. He was put on the 11-7 shift and counseled. She did not think she needed to report the allegation, as she investigated it and did not substantiate it. She said the employee talked loudly. She said she had copies of the investigation She said Resident #47 had complained about him, as well as another resident. He was not to go into her room. Review of the investigation provided by the DON, on 06/15/11 at 04:24 p.m., found that, on 03/28/11, a family member of Resident #47 did not want Employee #52 in the resident's room, as she feels that he talks down and yells at her grandmother. He is loud. 2. Another complaint was reported by Resident #15 against Employee #52 on 04/27/11. In a typed statement dated 04/27/11 at 0830, the DON reported (quoted as typed): On April 27, 2011 I was called into resident (name of Resident #… | 2015-11-01 |
| 9499 | 9499 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 226 | F | 0 | 1 | DLX411 | Based on resident interview, staff interview, review of the facility's internal investigations into allegations of abuse / neglect, and review of the facility's policy regarding abuse prevention, the facility failed to develop and implement policies and procedures for abuse reporting consistent with State law. The facility's policy for abuse reporting referred to California laws and agencies and did not address the specific reporting requirements outlined in West Virginia (WV) state law and the Abuse Reporting Memorandum issued by the WV survey and certification agency. This practice has the potential to affect all residents of the facility. Resident identifiers: #47 and #15. Facility census: 47. Findings include: a) Residents #47 and #15 1. During an interview on 06/14/11 at 9:57 a.m., Resident #47 reported that a nursing employee screamed at her like she was a dog. She stated, I can't walk, and one night we got up and I couldn't walk. The woman that works with him is not up to par. He talked to me like a dog and told me I should just stay in the bed and keep my mouth shut. She said she did not tell anyone about this, as she did not feel it would do any good. An interview with social worker (Employee #8), on the mid-afternoon of 06/15/11, found she had not received any complaints by residents about being yelled at by staff. During an interview with the director of nursing (DON) at 3:00 p.m. on 06/15/11, she said she had investigated a nursing assistant (Employee #52) for yelling. He was put on the 11-7 shift and counseled. She did not think she needed to report the allegation, as she investigated it and did not substantiate it. She said the employee talked loudly. She said she had copies of the investigation She said Resident #47 had complained about him, as well as another resident. He was not to go into her room. Review of the investigation provided by the DON, on 06/15/11 at 04:24 p.m., found that, on 03/28/11, a family member of Resident #47 did not want Employee #52 in the resident's room, as she feels that… | 2015-11-01 |
| 9500 | 9500 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 250 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide medically-related social services for one (1) of twenty-seven (27) Stage II sample residents. Resident #43 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Inventory of Personal Effects, dated 11/22/10, disclosed the resident's glasses were broken when she arrived at the facility. Review of the resident's activity assessment, dated 11/22/10, disclosed the resident had vision impairment and she enjoyed reading newspapers and magazines and watching soap operas and baseball games on TV. Review of the social services assessment, dated 11/23/10, found documentation indicating the family was to have the resident's glasses repaired. During the course of the survey, Resident #43 was observed wearing no glasses, and record review disclosed no further documentation by social services regarding plans to have the resident's glasses repaired or replaced. Resident #43 exhibited behaviors of wandering throughout the facility which were disruptive to other residents (by going in and out of their rooms), and she received antipsychotic and anti-anxiety drugs for these behaviors. She had no glasses which would have allowed her to engage in activities reflective of her interests, which could potentially assist with reducing her disruptive behaviors and improve her quality of lilfe. Resident identifier: #43. Facility census: 47. Findings include: a) Resident #43 Observations of Resident #43, throughout the course of the survey event from 06/14/11 to 06/22/11, found the resident wandered throughout the facility during the day in a wheelchair. Interviews conducted with alert, oriented residents during the course of the survey revealed Resident #43 wandered into other residents' rooms during the day and night, which the other residents found to be disruptive. These residents stated the stop signs posted acros… | 2015-11-01 |
| 9501 | 9501 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 253 | E | 0 | 1 | DLX411 | Based on observation, staff interview, and review of a proposal for improvements, the facility failed to provide housekeeping and maintenances services necessary to maintain a sanitary, orderly, and comfortable environment. Rooms, bathrooms, and hallways were in disrepair. Doors were scuffed with varnish worn and/or scraped off. Walls in the hallways and rooms had holes in the plaster and were chipped and scuffed. Door facings had paint that was chipped or scraped off. Some of the walls and facing areas were painted with a different colored paint in order to cover up the chipped and scraped areas. Cove based was marred, scuffed, and in some areas had broken or missing areas. Floors around the door facings were dirty and had not been cleaned. Bathrooms had scuffed and scratched walls, with heating units that were rusting and dirty. Ceiling vents were dirty. This had the potential to affect all residents in the facility. Pervasive, musty, stale odors were noted in East Wing resident rooms, bathrooms, and hallways, in the dining room, and hallway beside the nursing station. This had the potential to affect more than an isolated number of residents. Facility census: 47. Findings include: a) East Hall, Beauty Shop, and Dining Room 1. East Hallway Observation of the East hallway with the maintenance supervisor (Employee #27) on 06/15/11 at 4:30 p.m. found the following: - Rooms #15, #16, #17, #18, #19, #10, #20, #21, #22, #23, #24, and #25 had dirty ceiling vents. The doors to the rooms, the closet doors, the bathroom doors, and the built-in drawers and bedside tables were chipped, scratched, and had varnish that was worn off, exposing the wood. The walls were scuffed and marred. Door frames were also scuffed, marred, and had different colors of paint on them. The cove base located at the bottom of the walls was scuffed, missing, and loose in various places. - Heating and air conditioning units in the rooms and bathrooms were rusted and marred / scuffed, and had paint peeling from them. - Corners at bottom of the cove … | 2015-11-01 |
| 9502 | 9502 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 272 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to conduct an accurate comprehensive assessment of a resident's vision needs for one (1) of twenty-seven (27) Stage II sample residents. Review of Resident #43's initial minimum data set assessment (MDS), in Section B, found Item B1000 was coded to indicate the resident's vision was adequate and that she could see fine detail, including regular print in newspapers and books. Item B1200 was coded to indicate that corrective lenses were used when assessing her vision for B1000. Interviews conducted with staff, and observations of this resident during the course of the survey, found the resident was not wearing glasses. Interview with the registered nurse (RN) MDS coordinator found she had no knowledge of the extent of the resident's visual impairment and that glasses were not worn when completing Item B1000 of the MDS. Resident identifier: #43. Facility census: 47. Findings include: a) Resident # 43 Observations of Resident #43, throughout the course of the survey event from 06/14/11 to 06/22/11, found the resident wandered throughout the facility during the day in a wheelchair. Interviews conducted with alert, oriented residents during the course of the survey revealed Resident #43 wandered into other residents' rooms during the day and night, which the other residents found to be disruptive. These residents stated the stop signs posted across their doorways did not deter this resident from entering their rooms. Review of the resident's activity assessment (completed on admission on 11/22/10) disclosed the resident enjoyed watching soap operas and baseball games on TV and reading newspapers and Good Housekeeping magazines. She was also noted to have impaired vision. Review of the resident's Inventory of Personal Effects, dated 11/22/10, found the resident had eyeglasses, but the glasses were broken on admission. Interviews conducted with d… | 2015-11-01 |
| 9503 | 9503 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 279 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop care plans, based on an accurate comprehensive assessment, to meet each resident's individual needs, for two (2) of twenty-seven (27) Stage II sample residents. The facility fail to develop a care plan for a resident on antipsychotic medication, which identified the behaviors to be monitored by staff and what non-pharmacological interventions staff was to use in an effort to reduce these behaviors. The facility also failed to develop a care plan to address the desired activity interests / needs and impaired vision of a resident whose wandering behavior was disruptive to others. Resident identifiers: #57 and #43. Findings include: a) Resident #57 Record review revealed Resident #57 was admitted to the facility on [DATE], with prescriptions for an antipsychotic medication one (1) tablet twice daily for agitation and an antidepressant daily at bedtime. The resident's admitting [DIAGNOSES REDACTED]. Record review revealed a pharmacist's Consultation Report dated 04/02/11, notifying the physician that Resident #57 takes an antipsychotic, [MEDICATION NAME] for Depression, but does not have an appropriate associated diagnosis. In response, the physician wrote, on 04/08/11, that Resident #57 had a Dementing illness with associated behavioral symptoms. Review of Resident #57's care plan revealed no mention of psychotic behaviors to be monitored or any non-pharmacological interventions to be used to reduce these behaviors. Review of the medical record revealed the April 2011 Psychoactive Medication Monthly Flow Record had no targeted behavioral symptoms other than refusal to use a wheelchair despite safety education. Review of the May 2011 Psychoactive Medication Monthly Flow Record revealed a targeted behavior of teasing or tearing (illegible). Review of the June 2011 Psychoactive Medication Monthly Flow Record had no targeted behavioral symptoms. During an interv… | 2015-11-01 |
| 9504 | 9504 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 282 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed, for one (1) of twenty-seven (27) Stage II sample residents, to provide services as established in his written plan of care. The resident was noted to be seated in a wheelchair each day during the survey. There was a lap buddy in place at all times while he was in the wheelchair, even during meal times. The resident's care plan contained an intervention directing staff to remove the lap buddy during meals in the dining room and when participating in activities. Resident identifier: #61. Facility census: 47. Findings include: a) Resident #61 Resident #61 was observed on each morning of the survey to be seated in a wheelchair with a lap buddy in place. The resident was most frequently sleeping in the wheelchair with his arms resting on the lap buddy. The resident's medical record, when reviewed on 06/21/11, disclosed that he was admitted to the facility on [DATE] and had almost immediately experienced a fall. The physician ordered a lap buddy to be applied to prevent falls from the wheelchair. The resident's care plan (last reviewed on 05/18/11) related to the use of this lap buddy was reviewed stated the lap buddy was to be removed during meals in the dining room and when he was participating in activities. The resident was observed on 06/21/11 at 12:50 p.m. in the dining area of the facility, sitting at the table with his wife assisting him to eat. The lap buddy was in place at that time. This observation was confirmed by the facility's director of nurses (Employee #11) at the time it was observed. The lap buddy was then removed for the remainder of the meal. | 2015-11-01 |
| 9505 | 9505 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 309 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed, for one (1) of twenty-seven (27) Stage II sample residents, to provide care and services to assist the resident in attaining the highest level of physical well-being. Resident #16 sustained a skin tear, and care was not provided to the area as ordered by the physician. Resident identifier: #16. Facility census: 47. Findings include: a) Resident #16 Observation, during a random tour of the facility on 06/14/11 beginning at 10:00 a.m., found Resident #16 sitting in her room with a gauze dressing to her right wrist. Upon closer observation, the dressing was dated as applied on 06/10/11. The current treatment administration record (TAR) for this resident was requested and reviewed. The TAR made no mention of a dressing to the right wrist. The facility's director of nurses (DON - Employee #11) was asked to observe the area and confirmed that the dressing in place at this time had been applied on 06/10/11 and also that the resident's current TAR made no mention of a dressing to the resident's right wrist. The facility's treatment nurse (Employee #10) on this day (06/14/11) was asked to remove the dressing for observation. Upon removal of the dressing, there was no skin irregularity to observe beneath the dressing. Below the dressing, on the resident's upper thumb area was noted a skin tear covered with two (2) steri-strips. Employee #10 stated it appeared the dressing had slipped off of its intended location (upper thumb area) and migrated to her wrist. When reviewed on 06/14/11, Resident #16 physician's orders [REDACTED].') NS (normal saline), and pat dry. Also apply [MEDICATION NAME] & Kling change dressing qd (every day). The DON reviewed all the above findings and confirmed the affected skin on this resident's right hand had not been treated as ordered by the physician. | 2015-11-01 |
| 9506 | 9506 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 313 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide assistance in making arrangements for the repair / replacement of glasses for one (1) of twenty-seven (27) Stage II sample residents. Resident #43 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Inventory of Personal Effects, dated 11/22/10, disclosed the resident's glasses were broken when she arrived at the facility. Review of the resident's activity assessment, dated 11/22/10, disclosed the resident had vision impairment and she enjoyed reading newspapers and magazines and watching soap operas and baseball games on TV. Review of the social services assessment, dated 11/23/10, found documentation indicating the family was to have the resident's glasses repaired. During the course of the survey, Resident #43 was observed wearing no glasses, and record review disclosed no further documentation by social services regarding plans to have the resident's glasses repaired or replaced. Resident #43 exhibited behaviors of wandering throughout the facility which were disruptive to other residents (by going in and out of their rooms), and she received antipsychotic and anti-anxiety drugs for these behaviors. She had no glasses which would have allowed her to engage in activities reflective of her interests, which could potentially assist with reducing her disruptive behaviors and improve her quality of life. Resident identifier: #43. Facility census: 47. Findings include: a) Resident # 43 Observations of Resident #43, throughout the course of the survey event from 06/14/11 to 06/22/11, found the resident wandered throughout the facility during the day in a wheelchair. Interviews conducted with alert, oriented residents during the course of the survey revealed Resident #43 wandered into other residents' rooms during the day and night, which the other residents found to be disruptive. These resi… | 2015-11-01 |
| 9507 | 9507 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 323 | E | 0 | 1 | DLX411 | Based on observation and staff interview, the facility failed to ensure the resident environment was free of accident hazards over which the facility had control. Observation of water temperatures taken at hand sinks in five (5) resident rooms located closest to the facility's hot water tanks and kitchen area found the hot water tested greater than 110 degrees Fahrenheit (F). According to State law, water temperatures shall be appropriate for comfortable use but shall not exceed 110 degrees F (64CSR13-9.9.d.1.). This practice had the potential to affect more than an isolated number of residents. Facility census: 47. Findings include: a) During the investigation into safe water temperatures on 06/21/11 at 2:45 p.m., the facility's maintenance director (Employee #27) tested the hot water at the hand sinks in rooms #8, #14, #25, #26, and #28. These rooms were selected due to their close proximity to the hot water tanks and kitchen area. The hot water temperatures were: - 115 degrees F in room #8 - 120 degrees F in room #14 - 115 degrees F in room #25 - 120 degrees F in room #26 - 120 degrees F in room #28 According to federal regulations, exposure to a water temperature of 120 degrees F for five (5) minutes can result in third degree burns to persons with fragile skin and other physical conditions related to the elderly. An interview with the maintenance director, on 06/21/11 at 3:00 p.m., revealed the facility's practice was to maintain hot water temperatures in resident care areas at 112 degrees F. It was also confirmed these temperatures were too hot for resident use. | 2015-11-01 |
| 9508 | 9508 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 329 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's drug regimen is free from unnecessary drugs, as evidenced by: administering an excessive dose (duplicate therapy) of antianxiety medications for an excessive duration; continuing medications recommended by the pharmacist for either a dose reduction or discontinuation without a physician's rationale for risks versus benefits for continuing the medications; using an antipsychotic medication on a PRN (as needed) basis at bedtime for agitation; and failing to monitor [MEDICAL CONDITION] functioning of a resident receiving [MEDICAL CONDITION] medications. This practice affected three (3) of twenty-seven (27) Stage II sample residents. Resident identifiers: #33, #58, and #61. Facility census: 47. Findings include: a) Resident #33 2. Review of physician's orders [REDACTED]. Additionally, [MEDICATION NAME] (an antipsychotic medication) was increased to 5.0 mg twice daily beginning 01/21/11. Review of the pharmacist's Consultation Report dated 06/05/11 revealed a recommendation to consider a dose reduction for [MEDICATION NAME] (perhaps to 0.5 mg twice daily) and discontinuation of the [MEDICATION NAME] 25 mg twice daily. In reply, the physician on 06/08/11 wrote No changes and asked: Is this not the pt. (patient) that is beating up other residents?????? However, the physician provided no rationale as to why the two (2) antianxiety medications were continued. At this time, the resident also continued receiving [MEDICATION NAME] 5 mg twice daily and [MEDICATION NAME] 7.5 mg (an antidepressant) at bedtime. Review of the 23rd edition of Mosby's Nursing Drug Reference book (which was found at the facility's nurses' station) revealed a precaution for [MEDICATION NAME] use in geriatric patients, and cautioned that this medication was not to be used for everyday stress or used longer than four (4) months; potential central nervous system side effects include confusion a… | 2015-11-01 |
| 9509 | 9509 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 371 | F | 0 | 1 | DLX411 | Based on observation, staff interview, and policy review, the facility failed to store, prepare, and serve food under sanitary conditions. Boxes observed in the dry storage and kitchen areas were stored in direct contact with the floor. Nursing staff, during the breakfast meal in the dining room on 06/14/11, did not ensure residents' hands were cleansed before eating and did not sanitize or wash their own hands between direct resident contact, after contact with other contaminated surfaces, and and after touching areas around their faces. This had the potential to affect all residents in the facility. Facility census: 47. Findings include: a) During the dining room meal observation on 06/14/11 at 7:20 a.m., nine (9) residents were in the dining room with one (1) nursing staff person present. Residents were sitting as staff brought them water to drink. The residents did not receive assistance or encouragement to wash / cleanse their hands. At 7:25 a.m., staff started to pass juice and milk to the residents. At 7:30 a.m., breakfast was available for distribution to the residents in the dining room. At 7:35 a.m., a nursing assistant touched Resident #18 and then her hair. She then went back to the window and picked up two (2) more meals and served the meals to other residents without first washing her hands. At 7:37 a.m., Resident #201 came into dining room, and Employee #6 put his clothing protector on after pushing him into the dining room. The employee did not wash her hands; she then took a bowl of food over to another resident. At 7:38 a.m., Employee #6 scratched her eye brow with her hand and did not wash or sanitize her hands. She picked up Resident #33's spoon and handed it to him. She then got food for another resident. She picked up Resident #33's empty coffee cup (the resident drank out of the cup before), picked up the coffee pot, and poured coffee into the cup. She handed the cup to a licensed practical nurse (LPN - Employee #46). She then took food to Resident #201. The employee still did not use hand … | 2015-11-01 |
| 9510 | 9510 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 428 | D | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for two (2) of twenty-seven (27) Stage II sample residents, to assure the consulting pharmacist recognized medication usage irregularities and reported these irregularities to the attending physician and the director of nursing (DON). One (1) resident did not have proper monitoring for the use of a thyroid stimulating medication, and another resident received a psychotropic medication on an as needed (PRN) basis without proper assessment of the need or outcome of the medication. Resident identifiers: #61 and #58. Facility census: 47. Findings include: a) Resident #61 The medical record of Resident #61, when reviewed on 06/16/11, disclosed the resident was admitted to the facility on [DATE] following hospitalization . The resident's discharge summary from the hospital, which accompanied him upon admission to the facility, stated the resident had been admitted to the hospital from home due to confusion, weight loss, anorexia, headache, and urinary retention. The resident underwent [REDACTED]. This discharge document made mention that his synthroid does was adjusted. The synthroid dose at the time of discharge from the hospital was 0.125 mg daily and remained at that dose currently. There was no thyroid function testing from the hospital on the resident's medical record at the facility. The resident's medical record was further reviewed, and there was no indication that thyroid function testing had been completed since the time of his admission to the facility. The DON confirmed, on the afternoon of 06/16/11, that, in view of the fact that the resident had apparently undergone a dosage adjustment of this thyroid medication shortly before arrival at the facility, a baseline level should have been obtained and that proper monitoring for the use of this medication had not been completed. The consulting pharmacist monthly medication regimen review for this resident was reviewed, and th… | 2015-11-01 |
| 9511 | 9511 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 441 | E | 0 | 1 | DLX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to establish and maintain an effective infection control program to help prevent the development and transmission of disease and infection. Nursing staff, during the breakfast meal in the dining room on 06/14/11, did not ensure residents' hands were cleansed before eating and did not sanitize or wash their own hands between direct resident contact, after contact with other contaminated surfaces, and and after touching areas around their faces. The facility did not always investigate infections in the facility and did not maintain a record of all incidents and corrective actions related to infections. One (1) of twenty-seven (27) Stage II sample residents (#18) had urinary tract infections (UTIs) that were not recorded on the infection control logs. A nurse who was observed during medication pass did not wash her hands after resident contact (Resident #6) for one (1) of ten (10) residents observed. This had the potential to affect all residents. Facility census: 47. Findings include: a) During the dining room meal observation on 06/14/11 at 7:20 a.m., nine (9) residents were in the dining room with one (1) nursing staff person present. Residents were sitting as staff brought them water to drink. The residents did not receive assistance or encouragement to wash / cleanse their hands. At 7:25 a.m., staff started to pass juice and milk to the residents. At 7:30 a.m., breakfast was available for distribution to the residents in the dining room. At 7:35 a.m., a nursing assistant touched Resident #18 and then her hair. She then went back to the window and picked up two (2) more meals and served the meals to other residents without first washing her hands. At 7:37 a.m., Resident #201 came into dining room, and Employee #6 put his clothing protector on after pushing him into the dining room. The employee did not wash her hands; she then took a bowl of food over to another re… | 2015-11-01 |
| 9512 | 9512 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-06-22 | 464 | F | 0 | 1 | DLX411 | Based on observation, resident interview, staff interview, and a review of the facility's blueprints, the facility failed to provide adequate space to accommodate resident dining and activities. This had the potential to affect residents who utilized the activities and dining areas. Facility census: 47. Findings include: a) Observations made during the survey, from 06/14/11 through 06/22/11, found residents who utilized the dining room for meals and activities had a hard to accessing tables and places to sit without having to move other residents from one area to another. During meal observations on 06/14/11, there were twenty-five (25) residents in the dining room. The dining room contained seven (7) tables with twenty-eight (28) chairs, a piano in one corner, and a counter connected to the kitchen where food was placed for staff to pick up and serve to residents. When residents arrived they were seated at the tables and often having to be relocated to other places as more residents arrived. Residents could not be seated without having to move chairs and other residents. Residents were also found taking their meals in an alcove called the women's lounge with a television set in it. The alcove contained two (2) tables, chairs, and lifts, as well as the residents who were eating there. b) Observations also found the main activities took place in the dining room. The facility census was forty-seven (47), and the dining room was not large enough to accommodate all of the residents if they wanted to attend at the same time. c) The activity director, when interviewed on 06/13/11 at 2:00 p.m., said the main activities go on the dining room and the women's lounge. She said she was asked to move the activities department around the first of May 2011 to the old therapy room, as the therapy department needed more space. She said she used the current room for storage, and activities did not take place in this room. An confidential interview with an alert and oriented resident also confirmed this. On 06/14/11 at 10:00 a.m., … | 2015-11-01 |
| 9991 | 9991 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2012-11-28 | 520 | F | 0 | 1 | R8A112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, and staff interviews, the facility's quality assurance program failed to develop and implement effective plans of action to correct identified quality deficiencies. Four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12, were still out of compliance during the re-visit survey which ended 11/28/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F280, F281, F282, and F371. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) Staff interview with Employee #53 (QA Committee Contact Person), at 11:00 a.m. on 11/27/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). Employee #53 confirmed the QA Committee had been presented with the entire plan of correction at their meeting on 11/01/12. Employee #53 confirmed the plan of correction, including those in which the QA committee was not expressly mentioned, was discussed during this meeting. The QA committee did not ensure the deficient practices cited during the survey which ended 09/27/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F280, F281, F282, and F371. They remained out of compliance when evaluated for compliance during the revisit survey which ended 11/28/12. b) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. c) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A … | 2015-08-01 |
| 9992 | 9992 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2012-11-28 | 490 | F | 0 | 1 | R8A112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, and staff interviews, it was determined the facility was not administered in a manner which enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained his/her highest practicable well-being. There was a failure to fully implement the plan of correction for four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12. During the 11/28/12 revisit, deficiencies at F280, F281, F282, and F371 remained out of compliance. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. The failure to revise care plans was cited at F280 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. b) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A staff member initialed medications as given prior to the residents taking the medications. The failure to ensure services were provided in accordance with professional standards of practice was cited at F281 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. c) The facility failed to follow physician's orders [REDACTED].#32, and failed to follow physician's orders [REDACTED].#31. The failure to ensure services were provided in accordance with the written plan of care was cited at F282 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a rep… | 2015-08-01 |
| 10560 | 10560 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 309 | G | 1 | 0 | V0KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to provide necessary care and services to assure an optimal state of physical health. A diabetic resident exhibited excessively high blood sugar levels, a change in level of consciousness, and ultimately a [MEDICAL CONDITION] resulting in hospitalization . The facility had received a physician's orders [REDACTED]. Hospital records contributed the drastic elevations in blood sugar levels and the [MEDICAL CONDITION] to an unrecognized and untreated urinary tract infection. Resident identifier: #6. Facility census: 47. Findings include: a) Resident #6 The medical record of Resident #6, when reviewed on 07/13/11, disclosed this [AGE] year old female had resided at the facility for quite some time but had recently been hospitalized and returned to the facility on [DATE]. The resident's had been hospitalized with a [MEDICAL CONDITIONS] - a blood clot in a deep vein of the leg. Additional medical [DIAGNOSES REDACTED]. - Shortly following her return to the facility, on 06/23/11 at 10:15 am, a nurse documented the following: "Resident c/o (complained of) back of head hurting and dizzy. Dr. (name) was present in the house. B/P (blood pressure) for this resident 110/60, blood sugar 299. Temp (temperature) 98.1 afebrile. After sitting for a while resident felt better. Resident unable to finish therapy session due to being tired." Following this incident on this same day (06/23/11), the resident's daughter requested a urinalysis be completed, and the attending physician gave an order for [REDACTED]. A urine specimen was collected and tested via "dip-stick" by facility staff. A nurse's note, dated 06/23/11 at 12:40 p.m., stated, "Urine obtained via clean catch and dipstick (+) (positive) for leukocytes." The entry further stated that the lab would pick up the urine specimen that day. A nurse's note, dated 06/28/11 at 4:30 p.m., stated, "Dr (name) … | 2015-02-01 |
| 10561 | 10561 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-10-25 | 282 | G | 1 | 0 | 4BDR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders for one (1) of nine (9) sampled residents, when staff failed to provide cardio-pulmonary resuscitation (CPR) in the event of a cardiac or [MEDICAL CONDITION] arrest for a resident who was a full-code status. This omission was identified by staff, and the facility promptly took corrective action to prevent any recurrence for other residents. Resident identifier: #46. Facility census: 43. Findings include: a) Resident #46 Review of nursing notes found Resident #46 expired on [DATE], while sitting in his wheelchair during a planned activity for residents. Staff was present and close by when he expired suddenly and unexpectedly, although the exact moment of death was not known. Further review of nursing notes found that no cardio-pulmonary resuscitation (CPR) was performed. The resident was wheeled back to his room by aides and nurses, where post-mortem care was provided. The physician and family were then notified of his death, and the funeral home was called to transport the body. Review of his closed medical record found this resident was determined by his physician, upon his admission to the facility two (2) years earlier, to lack the capacity to understand and make informed health care decisions related to [MEDICAL CONDITION] / dementia. His wife was named his health care surrogate, and she expressed her desire for Resident #46 to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest (making him a "Full Code"). Further review of the medical record found physician's orders for [DATE] which stated: "[DATE]: FULL CODE", which directed staff to start CPR in the event that Resident #46 ceased breathing or his heart stopped beating. Review of the incident report and witness statements, completed by the former director of nursing (DON) related to Resident #46 not receiving CPR, found in her summary: "After the fact, the resident was then found… | 2015-02-01 |
| 10562 | 10562 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-10-25 | 309 | G | 1 | 0 | 4BDR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders for one (1) of nine (9) sampled residents, when staff failed to provide cardio-pulmonary resuscitation (CPR) in the event of a cardiac or [MEDICAL CONDITION] arrest for a resident who was a full-code status. This omission was identified by staff, and the facility promptly took corrective action to prevent any recurrence for other residents. Resident identifier: #46. Facility census: 43. Findings include: a) Resident #46 Review of nursing notes found Resident #46 expired on [DATE], while sitting in his wheelchair during a planned activity for residents. Staff was present and close by when he expired suddenly and unexpectedly, although the exact moment of death was not known. Further review of nursing notes found that no cardio-pulmonary resuscitation (CPR) was performed. The resident was wheeled back to his room by aides and nurses, where post-mortem care was provided. The physician and family were then notified of his death, and the funeral home was called to transport the body. Review of his closed medical record found this resident was determined by his physician, upon his admission to the facility two (2) years earlier, to lack the capacity to understand and make informed health care decisions related to [MEDICAL CONDITION] / dementia. His wife was named his health care surrogate, and she expressed her desire for Resident #46 to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest (making him a "Full Code"). Further review of the medical record found physician's orders for [DATE] which stated: "[DATE]: FULL CODE", which directed staff to start CPR in the event that Resident #46 ceased breathing or his heart stopped beating. In addition to his physician orders, documentation of his full code status was found elsewhere in social service progress notes as recently as [DATE], in the "Condition Alert - Bulletin Board" located on the front… | 2015-02-01 |
| 10859 | 10859 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-08-25 | 246 | D | 1 | 0 | RIOG11 | . Based on a random opportunity for observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs and preferences regarding one (1) resident's environment when he chose to eat his lunch in his room. Staff behaviors were not directed toward assisting the resident in maintaining independent functioning or dignity when they failed to turn on the lights in the resident's room while he ate his noon meal. Resident identifier: #4. Facility census: 45. Findings include: a) Resident #4 A random observation, on 08/25/11 at 12:15 p.m., found this resident was eating lunch in his room. It was a rainy and dull day, and the room appeared dim. Further observation revealed the light had not been turned on for the resident. Additionally, the curtain between the beds in the room was pulled, blocking any potential light from the window on the other side of the room. Upon inquiry, the resident stated he would like the light turned on so he could see what he was eating. At 12:25 p.m., an interview was conducted with a lead nursing assistant (Employee #30) and the minimum data set coordinator (Employee #4). Each of these employees confirmed staff should have turned on the resident's light when his meal was served. . | 2014-12-01 |
| 10860 | 10860 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-08-25 | 225 | E | 1 | 0 | RIOG11 | . Based on record review and staff interview, the facility failed to evaluate and /or investigate eighteen (18) unwitnessed and unexplained bruises affecting twelve (12) facility residents. Thirty-six (36) incidents of unknown bruising were reviewed for the period of 07/01/11 through 08/19/11. There was no evidence eighteen (18) of the thirty-six (36) unwitnessed incidents of bruising, affecting twelve (12) residents, were investigated to rule out potential abuse or neglect. Resident identifiers: #3, #47, #6, #15, #48, #20, #21, #36, #32, #35, #29, and #41. Facility census: 43. Findings include: a) Resident #21 An Event Management Report (EMR) for Resident #21, dated 07/20/11, noted two (2) bruises on the left forearm. A second EMR for Resident #21, dated 07/27/11, noted three (3) bruises on the right forearm measuring 3 cm x 2 cm, 10 cm x 3 cm, 8 cm x 4 cm respectively. A third EMR for Resident #21, dated 08/15/11, noted a discoloration to the right forearm measuring 11 cm x 4 cm. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruises for any of these bruises of unknown origin to rule out potential abuse or neglect for this resident. - b) Resident #20 An EMR for Resident #20, dated 07/11/11, noted a bruise on right upper arm. The cause noted on the EMR was: "? Hoyer lift." There was no evidence the facility evaluated and/or investigated whether or not the use of a Hoyer lift actually caused this bruise of unknown origin. - c) Resident #41 An EMR for Resident #41, dated 08/01/11, noted a bruise on the right side of the resident's body and a second on the resident's right upper arm. There was no evidence the facility evaluated and/or investigated possible cause(s) of the bruises of unknown origin to rule out potential abuse or neglect for this resident. - d) Resident #47 An EMR for Resident #47, dated 07/04/11, noted four (4) bruises on the left arm, one (1) bruise on the left knee, and one (1) bruise on the inner aspect of the left leg. There was no evidence the facility… | 2014-12-01 |
| 10861 | 10861 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-08-25 | 312 | D | 1 | 0 | RIOG11 | . Based on observation, resident interview, staff interview and record review, the facility failed to provide the necessary services for one (1) of sixteen (16) sample residents whose grooming and personal hygiene needs had increased. The resident had been independent in grooming and personal hygiene, but these abilities had declined. The facility failed to assess and care plan the resident's current activity of daily living (ADL) needs; therefore, the resident did not consistently receive the grooming and personal hygiene services she required. Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 Observation, on 08/23/11 at 9:25 a.m., found this resident wearing a tee-shirt top and blue sweat pants. The resident's hair was clean and combed around her face, but it was sticking up in the back. The resident was later observed in the dining room, at 11:15 a.m. this same day. Her hair was still flat and sticking up in the back. An observation made in the resident's room, at 11:25 a.m. on 08/24/11, revealed the resident had a strong smell of urine. Additionally, her hair was greasy and uncombed. The resident was in bed wearing the same blue sweat pants as she had worn on the morning of 08/23/11. - On 08/24/11, the admission and two (2) quarterly MDSs were reviewed. The admission MDS had an assessment reference date of 02/06/11, and the quarterly MDSs were completed in April 2011 and July 2011. Under Section G (Functional Status) of these MDSs, Resident #24 was coded as requiring no help or staff oversight at anytime, and she required set-up help only with bathing, personal hygiene (which includes combing hair), and toilet use. Under Section H, both urinary incontinence and bowel incontinence were coded continent. - An observation, on 08/25/11 at 8:45 a.m., revealed the resident was in bed wearing the same blue sweat pants she had worn on the morning of 08/23/11. The front of the blue sweat pants had multiple food crumbs all over them. The resident had a strong urine odor, and her hair was g… | 2014-12-01 |
| 10862 | 10862 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-08-25 | 274 | D | 1 | 0 | RIOG11 | . Based on observation, staff interview and record review, the facility failed to accurately assess the care needs for one (1) of sixteen (16) sample residents. The resident had experienced a significant decline in the self-performance of bathing and personal grooming, and this decline was not identified in the current minimum data set (MDS). Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 Observation, on 08/23/11 at 9:25 a.m., found this resident wearing a tee-shirt top and blue sweat pants. The resident's hair was clean and combed around her face, but it was sticking up in the back. The resident was later observed in the dining room, at 11:15 a.m. this same day. Her hair was still flat and sticking up in the back. An observation made in the resident's room, at 11:25 a.m. on 08/24/11, revealed the resident had a strong smell of urine. Additionally, her hair was greasy and uncombed. The resident was in bed wearing the same blue sweat pants as she had worn on the morning of 08/23/11. - On 08/24/11, the admission and two (2) quarterly MDSs were reviewed. The admission MDS had an assessment reference date of 02/06/11, and the quarterly MDSs were completed in April 2011 and July 2011. Under Section G (Functional Status) of these MDSs, Resident #24 was coded as requiring no help or staff oversight at anytime, and she required set-up help only with bathing, personal hygiene (which includes combing hair), and toilet use. Under Section H, both urinary incontinence and bowel incontinence were coded continent. - An observation, on 08/25/11 at 8:45 a.m., revealed the resident was in bed wearing the same blue sweat pants she had worn on the morning of 08/23/11. The front of the blue sweat pants had multiple food crumbs all over them. The resident had a strong urine odor, and her hair was greasy and uncombed. When the resident was asked where she took her bath or showered, the resident pointed to the bathroom door in her room. Upon inspection, the bathroom contained a toilet and sink. There wa… | 2014-12-01 |
| 10863 | 10863 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-08-25 | 280 | D | 1 | 0 | RIOG11 | . Based on staff interview and record review, the facility failed to revise the care plan for one (1) of sixteen (16) sample residents when the resident experienced an increased need for staff assistance with bathing and grooming. Resident identifier: #25. Facility census: 43. Findings include: a) Resident #25 A review of the care plan for Resident #25 was conducted in the afternoon of 08/24/11. The care plan, completed on 07/20/11, stated the resident "requires setup / supervision with dressing, personal hygiene, and bathing." - On 08/25/11 at 8:55 a.m., an interview was conducted with two (2) nursing assistants (NAs). These NAs (Employees #30 and #46) stated they were familiar with Resident #25. When asked when the resident received a shower, Employee #30 stated the resident did her own bath in her room and, sometimes, another NA (Employee #46) could get the resident to take a shower. Employee #46 stated, "Sometimes I can get her to go to the shower." When asked about the strong urine smell, Employee #30 stated, "I wash her bottom and back if she will let me." Employee #30 further stated, "She is not able to clean herself well and still smells of urine even though the resident said she had taken a bath." Both Employees #30 and #46 agreed the resident was no longer able to independently do her own bath and hair - On 08/25/11 at 10:30 a.m., an interview was held with the MDS coordinator (Employee #4) and Employee #30. Employee #30 explained the resident was not able to comb her hair or take a bath independently and stated, "I wash her bottom and back if she will let me." A review of the MDS, care plan, and NA documentation forms was conducted with the MDS coordinator at that time. The MDS coordinator explained the information on the NA documentation forms came from the care plan. The MDS coordinator said she was not aware of these changes in the resident's ADL self-performance status. At that time, Employee #4 agreed the information contained in Resident #25's care plan and NA forms did not accurately reflect the… | 2014-12-01 |
| 10956 | 10956 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 225 | E | 1 | 0 | V0KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and resident interview, the facility failed to report allegations of neglect; conduct an investigation of the alleged violations; and/or report the results of such investigations to State officials as required for four (4) sampled residents. Resident identifiers: #27, #30, #9, and #26. Facility census: 47. Findings include: a) Resident #27 A review of the medical record revealed Resident #27 was a self-ambulatory [AGE] year old male admitted originally on 12/28/07, and readmitted on [DATE]. A review of an event management report revealed that, at 7:25 a.m. on 06/29/11, Resident #27 was seen out of the facility "at top of parking lot". He had exited the facility through the therapy department's exit door. The door alarm from the resident hall into therapy had been disconnected, and no one had heard the Wanderguard alarm sound when he exited the building. Resident #27 resided in a room located approximately half-way between the exit door in question and the nurses' station. He had been identified as an exit-seeker, and his care plan stated: "1/2/11: Wanders (behavior deterioration)." Interventions included: "Wanderguard alert bracelet to prevent exiting without assistance." The resident was redirected back inside the facility by staff on 06/29/11, but this incident had a high potential for harm, as the facility is located on a curve of a highway in the direction the resident was found. This incident had not been reported to the appropriate State agencies as an allegation of neglect, and there was no evidence that an investigation had been undertaken, although it was known that the door alarm had been disabled. There was no evidence the identity of the person disabling the alarm was sought. During an interview with the administrator and the director of nurses (DON) at 3:00 p.m. on 07/13/11, the DON stated she had started an investigation, but she acknowledged the event had not been reported. She could n… | 2014-11-01 |
| 10957 | 10957 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 500 | E | 1 | 0 | V0KG11 | . Based on a review of the agreements with attending physicians and staff interview, the facility failed to ensure the attending physician for five (5) of forty-seven (47) residents in the facility made arrangements specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services and the timeliness of the services. Resident identifiers: #19, #34, #12, #10, and #6. Facility census: 47. Findings include: a) Residents #19, #34, #12, #10, and #6 Review of the facility's written agreements and contracts failed to find evidence that the attending physician for Residents #6, #10, #12, #19, and #34 had a written agreement with the facility that ensured he would provide services for the residents (including those with respect to supervision of care, review of care, notes, and orders at each visit, and frequency and timeliness of visits). The contract book only contained copies of the physician's license and proof of medical liability insurance. An interview with the director of nursing, on 07/12/11 at 4:00 p.m. found she did not believe the physician needed an agreement with the facility and that the facility only required proof of his license and insurance. . | 2014-11-01 |
| 10958 | 10958 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 501 | F | 1 | 0 | V0KG11 | . Based on policy review, review of medical director's contract, and staff interview, the facility failed to ensure the medical director was involved in implementation of care policies and the coordination of medical care in the facility. This has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from "Med Path", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or the drug formulary were ever reviewed or revised after the initial signature date of 09/28/09. The formulary in this manual was not the drug formulary in use by the facility. This was verified by the DON at 2:00 p.m. on 07/13/11, when she produced the drug formulary currently in use. - The DON also produced a Long Term Care Facility's Pharmacy Services and Procedure Manual from Omnicare, Inc. (the facility's contracted pharmacy vendor) dated May 2010. She stated that Omnicare provided an updated manual every year. This manual had a cover page with allowed for the recording of the signatures of the administrator, DON, medical director, and consultant on an an… | 2014-11-01 |
| 10959 | 10959 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 441 | D | 1 | 0 | V0KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to implement infection control practices for one (1) of five (5) residents reviewed who had been diagnosed with [REDACTED]. The resident had a recently diagnosed urinary tract infection, and direct care staff was not aware of this infection. Resident identifier: #30. Facility census: 47. Findings include: a) Resident #30 Review of the medical record for Resident #30, on 07/13/11, noted the resident had recently been treated for [REDACTED]. treatment for [REDACTED]. There had been no repeat lab studies to indicate the successful treatment of [REDACTED]. - A nursing assistant who was providing direct care for this resident on 07/13/11 (Employee #30), when asked if she was aware of any precautions related to the care of this resident, stated she was not. - The facility's policy / procedure related to care of residents with an MDRO was requested and received from the facility's director of nursing (DON) on the afternoon of 07/13/11. Review of this policy / procedure (which was not dated to indicate when it was adopted or revised by the facility) disclosed the following directives at Item #28: "Notify physicians and other healthcare personnel who provide care for the resident that the resident is colonized / infected with a multidrug-resistant organism." - The DON, when interviewed on 07/13/11 at 2:00 p.m., stated the resident had an indwelling urinary catheter and the source of the infection was contained. The DON could not, however, provide evidence that direct care staff was made aware of this resident's infection, as stated in facility policy / procedure. . | 2014-11-01 |
| 10960 | 10960 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 504 | D | 1 | 0 | V0KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to obtain a physician-ordered lab study. A resident exhibiting signs and symptoms of a urinary tract infection received a physician's orders [REDACTED]. The physician ordered that the specimen be recollected and submitted for testing. This second submission was not completed. Resident identifier: #6. Facility census: 47. Findings include: a) Resident #6 The medical record of Resident #6, when reviewed on 07/13/11, disclosed this [AGE] year old female had resided at the facility for quite some time but had recently been hospitalized and returned to the facility on [DATE]. The resident's had been hospitalized with a [MEDICAL CONDITIONS] - a blood clot in a deep vein of the leg. Additional medical [DIAGNOSES REDACTED]. - Shortly following her return to the facility, on 06/23/11 at 10:15 am, a nurse documented the following: "Resident c/o (complained of) back of head hurting and dizzy. Dr. (name) was present in the house. B/P (blood pressure) for this resident 110/60, blood sugar 299. Temp (temperature) 98.1 afebrile. After sitting for a while resident felt better. Resident unable to finish therapy session due to being tired." Following this incident on this same day (06/23/11), the resident's daughter requested a urinalysis be completed, and the attending physician gave an order for [REDACTED]. A urine specimen was collected and tested via "dip-stick" by facility staff. A nurse's note, dated 06/23/11 at 12:40 p.m., stated, "Urine obtained via clean catch and dipstick (+) (positive) for leukocytes." The entry further stated that the lab would pick up the urine specimen that day. A nurse's note, dated 06/28/11 at 4:30 p.m., stated, "Dr (name) notified of C&S (culture and sensitivity) report and orders received to repeat C&S." Review of the lab report related to this sample disclosed the urine specimen was contaminated. - Continued review … | 2014-11-01 |
| 10961 | 10961 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 493 | F | 1 | 0 | V0KG11 | . Based on policy review and staff interview, the governing body failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical well-being of each resident. A commercially-published nursing service policy manual was not reviewed, revised to reflect facility-specific activities, and formally adopted for use by the facility's administrative staff (including the administrator). The drug formulary found in the pharmacy manual was not the formulary currently in use. The dietary department policy manual was kept in the director of nursing (DON) office. Policy / procedure manuals from the facility's corporation were available on-line but were not revised to reflect facility-specific requirements or printed and/or otherwise available / accessible to staff for day-to-day use. In general, the policies and procedures intended to guide staff in the rendering of resident care / services and the day-to-day operations of this facility were not approved / adopted and readily available for use by staff. This practice has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from "Med Path", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pha… | 2014-11-01 |
| 10962 | 10962 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 520 | F | 1 | 0 | V0KG11 | . Based on policy review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware and develop / implement appropriate plans of action to correct these quality deficiencies. The facility's QAA committee failed to identify that policies and procedures intended to guide the rpovision of resident care and services and the day-to-day operations of the facility were not reviewed, adopted, revised (when applicable) by administrative staff (including the director of nursing, administrator, and medical director), nor did the QAA committee identify the need to make these policies and procedures available / accessible for use by staff. These quality deficiencies had existed since a change occurred in the facility governing body in July 2010, and no plan had been instituted to correct them. this practice has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from "Med Path", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or th… | 2014-11-01 |
| 11145 | 11145 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 225 | E | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure three (3) incidents of resident-to-resident altercations (involving four (4) residents) which required physician intervention were immediately reported to the State survey and certification agency in accordance with the Abuse Reporting Memorandum issued by the State survey agency to all nursing facilities in 2001. Resident identifiers: #51, #8, #17, and #43. Findings include: a) Resident #8 An interview with Resident #8, during tour on 08/10/09, found the resident had a fading bruise that extended from the top of the right arm to below the elbow. When asked how the injury occurred, Resident #8, who was alert and oriented, related that Resident #51 tried to force her way into Resident #8's room, and she put her cane against the partially opened door to stop Resident #51 from entering. Resident #51 then forced her way into Resident #8's room and took the cane from Resident #8, striking her in the head, arm, and leg. Resident #8 stated the bruise on the arm was a result of this incident. A review of incident / accident reports found this incident occurred on 07/27/09, but the bruise on the resident's arm was not reported by the resident to staff until 08/05/09. Resident #8 was seen by the physician on 08/06/09, who ordered x-rays of her arm and wrist. There were no fractures. Resident #51 was transferred to the hospital on [DATE], the day after Resident #8 reported the bruise to nursing staff. A 07/27/09 nursing note stated Resident #51 came into Resident #8's room, grabbed Resident #8's cane and hit her on the right inner knee and on the top of the head, causing her glasses to fall on the floor. No injuries were noted at that time, but the resident was upset, and one-on-one staff supervision was given. A review of the facility's abuse files found no evidence this was reported to the State survey agency. b) Resident #17 Review of the facility's incident / accident … | 2014-08-01 |
| 11146 | 11146 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 203 | D | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the transfer notice and staff interview, the facility failed to include the reason for the discharge on the written Notice of Transfer or Discharge for one (1) of thirteen (13) sampled residents (Resident #51). Facility census: 50. Findings include: a) Resident #51 Resident #51 was transferred to the hospital on [DATE]. Review of the transfer / discharge notice found in Resident #51's record disclosed no documented reason for discharge. A review of the notice was completed in the late afternoon with the social worker, and a request for additional information was made. As of exit at 7:00 p.m. on 08/12/09, no additional information was available. . | 2014-08-01 |
| 11147 | 11147 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 201 | D | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to afford one (1) of thirteen (13) sampled residents, who was transferred to the hospital, an opportunity to return to the facility. Resident #51 was transferred to the hospital for evaluation due to problem behaviors on 08/06/09, and after this transfer occurred, Resident #51's family was told the facility would not re-admit the resident. Facility census: 50. Findings include: a) Resident #51 Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical records prior to admission (dated 04/20/09) found, "... improved speech and walking with [MEDICATION NAME], but has become very aggressive and combative at times..." Review of the resident's nursing notes, from 05/31/09 through 08/06/09, and the facility's incident / accident reports found numerous resident-to-resident altercations involving Resident #51, including three (3) incidents which resulted in injury to the other residents. A psychological consult, dated 08/03/09, stated, "As per history of the last five years as given to me by family, patient has continued to deteriorate to present condition of full care and supervision, and has an extended history of combativeness and aggression as per family and nurses notes. As her present placement allows for freedom of movement, and social interaction between patients, I would recommend a more restrictive environment for the safety of patient and others." A 08/06/09 physician's orders [REDACTED]." A social service note, dated 07/24/09, stated, "... request him (Resident #51' medical power of attorney representative - MPOA) to call next week when he gets settled and we can have a meeting to discuss what is the best plan for (Resident #51's) safety." After requesting additional information on the late afternoon of 08/12/09, the social worker produced two (2) additional unsigned social services notes. A 08/06/09 note stated, ".… | 2014-08-01 |
| 11148 | 11148 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 154 | D | 0 | 1 | OCKG11 | Based on medical record review and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents was fully informed in advance of medication changes. Resident #8 was determined to possess the capacity to make her own health care decisions, but a note in the resident's medical record indicated her daughter, who was not a legally designated health care surrogate, was to be informed of medication changes before the resident was. Facility census: 50. Findings include: a) Resident #8 Resident #8 was an alert and oriented resident who had been determined by her physician to possess the capacity to understand and make her own health care decisions. Review of Resident #8's medical record found the following statement dated 02/24/09 and signed by the former director of nursing: "Nurses: Please contact (name) before ordering new medications for (Resident #8). She would like to talk it over with her mother first. The above is not to be discussed with (Resident #8)." A review of the statement with the current director of nursing, on 08/12/09 at 2:00 p.m., found the director of nursing was unaware of the note in the resident's medical record. . | 2014-08-01 |
| 11149 | 11149 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 159 | B | 0 | 1 | OCKG11 | Based on a review of the resident trust account information and staff interview, the facility failed to ensure quarterly account balances / statements were being sent only to persons with the legal authority to access this information. The facility sent quarterly account balances / statements to unauthorized third parties for four (4) residents. Resident identifiers: #11, #36, #30, and #33. Facility census: 50. Findings include: a) Residents #11, #36, #30, and #33 Record review for Residents #11, #30, #33, and #36 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal fund records, with the business office manager on 08/12/09 at 10:00 a.m., found quarterly financial statements were being sent to unauthorized representatives for all four (4) residents, two (2) of whom were alert and oriented and were entitled to this information themselves. . | 2014-08-01 |
| 11150 | 11150 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 161 | E | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a surety bond in sufficient amount to assure the security of all personal funds of residents deposited with the facility. This had the potential to affect any residents who utilized the facility to keep their personal account funds. Facility census: 50. Findings included: a) A review of information provided by the administrator, on [DATE], found the facility did not have a current surety bond to assure the security of all personal funds of residents deposited with the facility. This was verified via e-mail communication on [DATE] with the Office of Health Facility and Certification, the State agency designated as holder of surety bonds for nursing facilities. A surety bond in the amount of $2500.00 (Bond # SU,[DATE]) expired on [DATE], and it was not renewed. The total of resident funds deposited at the facility was $1474.51. On [DATE] at 5:30 p.m., the administrator reported the facility had $100,000 liability insurance, he but could not find any other information regarding this prior to exit at 7:00 p.m. on [DATE]. --- NOTE: Commercial insurance may only be used to secure resident funds when specific conditions outlined in W.V. Code are met. For example, according to W.V.C. ,[DATE]C-7, "This insurance policy shall specifically designate the resident as the beneficiary or payee (sic) reimbursement of lost funds." . | 2014-08-01 |
| 11151 | 11151 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 205 | D | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written information regarding the facility's bed-hold policy to one (1) of thirteen (13) sampled residents, who was transferred to a hospital, to include the duration of the bed-hold policy under the State plan during which the resident would be permitted to return and resume residence in the nursing facility. Resident identifier: #51. Facility census: 50. Findings include: a) Resident #50 A review of Resident #51's closed medical record revealed Resident #51 was transferred to the hospital on [DATE]. Evidence that a copy of the facility's bed hold policy was provided to Resident #51's responsible party was not found in the medical record. On 08/12/09 at 10:00 a.m., a request for the information was made to the social worker. At exit on the evening on 08/12/09, no additional information was provided other than the social worker stating the resident was not returning to the facility, so no bed hold information was given to the resident or legal representative. . | 2014-08-01 |
| 11152 | 11152 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 226 | E | 0 | 1 | OCKG11 | Based on a review the facility's abuse policies and staff interview, the facility failed to develop policies and procedures for immediately reporting and thoroughly investigating resident-to-resident altercations resulting in the need for physician intervention, in accordance with the Abuse Reporting Memorandum issued by the State survey agency to all nursing facilities in 2001. This had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) Residents #8, #17, #43, and #51 were involved in resident-to-resident altercations resulting in injuries requiring physician intervention. (See citation at F225.) Ongoing interviews with the facility's director of nursing, administrator, and social worker, on 08/11/09 and 08/12/09, failed to find evidence that these incidents were reported to the State survey agency. They indicated they were unaware these needed to be reported. b) A review of the facility's abuse policies failed to find evidence that policies and procedures had been developed regarding the reporting of resident-to-resident altercations that required physician intervention. c) According to the Abuse Reporting Memorandum, issued by the State survey agency in June 2001, on page 2: "Resident to Resident and Visitor to Resident Abuse: Reporting requirements: In keeping with the Memorandum of 1994, RESIDENT TO RESIDENT and VISITOR TO RESIDENT abuse do not have to be reported to OHFLAC (the State survey agency) unless the abuse results in a need for physician intervention and/or transfer or discharge of the resident from the facility." . | 2014-08-01 |
| 11153 | 11153 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 241 | D | 0 | 1 | OCKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that one (1) of thirteen (13) residents who was admitted to the facility on [DATE] was able be dressed and out of bed. Resident #50 Findings included: a) Resident #50 was admitted to the facility on [DATE] and was clothed in a hospital gown. Ongoing observation of the resident on 08/10/09 through 08/12/09 found the resident was dressed in a hospital gown or t-shirt without any pants on. On 08/12/09 at 10:00 a.m. the social worker was interviewed and indicated the family was supposed to bring in clothing, but had not done so yet. The social worker and the assistant activity director found clothing for the resident on 08/12/09 and the resident was able to be gotten out of bed and seated in a geri-chair in the hall way. | 2014-08-01 |
| 11154 | 11154 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 152 | D | 0 | 1 | OCKG11 | Based on record review and staff interview, the facility allowed a resident to sign legal documents for health care decisions on the same day the resident's physician determined he did not possess the capacity to understand and make informed health care decisions and no one had been designated to serve as health care surrogate for the resident. Additionally, the physician failed to record the cause and duration of Resident #50's incapacity. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #50. Facility census: 50. Findings include: a) Resident #50 Record review revealed Resident #50 had a determination of incapacity statement signed by his attending physician at the facility. Record review also revealed that, on the same day the incapacity statement was signed by the physician, Resident #50 had signed the following documents: acknowledgment for bed rail use; acknowledgment of resident rights and privacy notice; immunization acknowledgment for declination of influenza vaccine; advance directives acknowledgment form; and permission to release information form. Interview with the social worker (Employee #8), on 08/12/09 at 2:00 p.m., revealed the resident had recently been admitted to the facility on her day off; he was accompanied by one (1) of his children. Employee #8 said, on the following day, she contacted one (1) of his children, who agreed to come in that day and speak with her, but the daughter did not appear. The next day, the physician assessed Resident #50 and determined he lacked the capacity to understand and make health care decisions. Employee #8 spoke her plans to have a yet-to-be assigned health care surrogate co-sign his legal documents, and she was in the process of making phone calls and going down the long list of family members to identify who was willing and able to serve as his health care surrogate. Interview with the social worker, on 08/12/09 at approximately 6:00 p.m., revealed she was still in the process of calling family members to determine who wa… | 2014-08-01 |
| 11155 | 11155 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 371 | F | 0 | 1 | OCKG11 | Based on record review and staff interview, the facility failed to store, prepare, and serve foods under sanitary conditions. Dietary staff failed to routinely monitor the water temperatures of the wash and final rinse cycles in the dishwasher to ensure they were maintained within the proper range to effectively sanitize dishware between uses. Dietary staff failed to routinely monitor the temperatures of the refrigerator, freezer, and ice cream freezer. Also, a nursing assistant failed to serve food to residents in the dining room without touching the food against her uniform. These practices had the potential to affect all residents. Facility census: 50. Findings include: a) On 08/12/09 at 2:00 p.m., review of the facility's August 2009 dishwasher temperature check log revealed places to record the wash temperature and final rinse temperature of the dishwasher three (3) times each day, for the breakfast, lunch, and dinner meals. Each of these items would have been measured and recorded twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. No temperatures were measured and recorded on 08/05/09, 08/06/09, 08/07/09, 08/08/09, 08/09/09, 08/10/09, and the temperatures were recorded only once on 08/04/09. The wash and final rinse temperatures were omitted a total of nineteen (19) times each for the month of August through 2:00 p.m. on 08/10/09. The dishwasher temperatures were checked at this time and the wash cycle was at 165 degrees Fahrenheit (F) and the rinse cycle at 180 degrees F. b) The refrigerator temperature check log revealed places to record the temperature of the refrigerator three (3) times each day, for the breakfast, lunch, and dinner meals. Each of these items would have been measured and recorded twenty-nine (29) times from 08/01/09 through 2:00 p.m. on 08/10/09. The refrigerator temperatures were omitted a total of seven (7) times. No temperature checks at all were measured and recorded on 08/09/09 and 08/10/09, and only temperatures were recorded once on 09/08/09. The temperature at t… | 2014-08-01 |
| 11393 | 11393 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 323 | G | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, h… | 2014-04-01 | ||
| 11394 | 11394 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 280 | D | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to review / revise their care plans with new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Resident identifiers: #19, #20, and #36. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have "bruising each side of her nose" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was "slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)." - On 11/25/10 at 8:30 p.m., a report stated, "Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash." - On 11/27/10 at 5:00 p.m., another report stated, "CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted." No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., "CNA walking past room (#) she saw resident … | 2014-04-01 | ||
| 9242 | 9242 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 246 | D | 0 | 1 | UNLT11 | Based on resident interview, observation and staff interview, the facility failed to ensure a resident's right to receive services with reasonable accommodation of individual needs. One (1) of twelve (12) Stage II sample residents did not have access to her call bell when she needed to be assisted to the bathroom. Resident identifier: #121. Facility census: 61. Findings include: a) Resident #121 On 05/11/11 at 9:07 a.m., during a conversation with the resident, she said she needed to go to the bathroom. She was seated in her wheelchair approximately two and one-half (2 -1/2) feet to the right of her bed. Her call bell was on the floor under her bed. It was also noted the resident had a cast on her right lower arm. While retrieving the resident's call bell for her, this surveyor inadvertently set off the resident's bed alarm. A nursing assistant (Employee #53) responded to the sound of the alarm in approximately two (2) minutes; at that time, he was informed of the resident's request to be taken to the bathroom. After assisting the resident out of the bathroom, Employee #53 asked whether the resident had used her call bell. He said they had been working with her to use her call bell when she needed to go to the bathroom. It was explained to him the call bell had been under the bed and the resident had been unable to reach the call bell. | 2016-01-01 |
| 9243 | 9243 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 274 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change assessment when indicated. One (1) of twelve (12) Stage II sample residents had experienced declines and improvements during the three (3) months between her admission assessment and the following quarterly assessment. These changes had the potential to affect her care needs. A comprehensive assessment was needed to determine possible causal factors for the declines and to determine what interventions might be implemented to reverse, or prevent further, declines. Resident identifier: #90. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission assessment with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines and improvements in a number of areas. The following changes were noted: 1. Her ability to understand and to be understood declined from usually to sometimes. 2. The score on her Brief Interview of Mental Status (BIMS) score declined from 11 to 3 (with a maximum score of 15). 3. In the section for signs and symptoms of [MEDICAL CONDITION], she had been coded as having none on the admission assessment, while the quarterly assessment indicated she had inattention and disorganized thinking. 4. Her quarterly assessment was coded as her having problems sleeping and feeling tired or having low energy, which had not been present on the admission assessment. 5. She did not have problems concentrating according to her admission assessment. Her quarterly assessment indicated she had problems in this area nearly every day. 6. Her admission assessment indicated she did not have physical behaviors or reject care, but the quarterly assessment indicated both of these were present one (1) to three (3) days a week. 7. She had wandered one (1) to three (3) days according to the admission assessment, but the quarterly assessment indica… | 2016-01-01 |
| 9244 | 9244 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 279 | D | 0 | 1 | UNLT11 | Based on medical record review, staff interview, and observation, the facility failed to develop care plans for two (2) of twelve (12) Stage II sampled residents to address care and services required to meet each resident's medical and nursing needs. Resident identifiers: #90 and #121. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines in continence. Her admission assessment indicated she was frequently incontinent of urine. The quarterly assessment was coded as always incontinent. She was also assessed as having declined from being always continent of bowel on her admission assessment to being frequently incontinent on her quarterly assessment. No care plan had been developed to address the declines in bowel and bladder continence in an attempt to restore her to prior levels of continence or to prevent further decline in these areas. -- c) Resident #121 Review of this resident's care plan found it was identified the resident had a cast on her right arm. However, it was not identified the resident's right side was her dominant side. The care plan did not identify what accommodations / adaptations needed to be implemented to assist the resident in maintaining as much independence as possible. For example, her call bell was on the floor to her right on 05/11/11. If the call bell had been on the bed, it still would have been difficult for the resident to access with her right hand. At lunch time on 05/18/11, observation found the cast on her right arm had been replaced with a splint. She continued to eat with her left hand. She was able to eat, but an adaptive device (such as a scoop plate, a plate guard, or a plate with a raised edge) would have been of benefit in making it easier for her to get food on her fork. | 2016-01-01 |
| 9245 | 9245 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 280 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to review / revise the care plans of two (2) of twelve (12) Stage II sample residents when changes were indicated in their care and treatment. Resident identifiers: #14 and #30. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resid… | 2016-01-01 |
| 9246 | 9246 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 309 | E | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's bowel protocol, the facility failed to institute the bowel protocol for five (5) of ten (10) residents experiencing constipation. Review of the residents' activities of daily living (ADL) flow sheets, medication administration records (MARs), and the facility's standing orders revealed these residents experienced constipation for more than three (3) days before the facility intervened. Resident identifiers: #44, #12, #54, #90, and #27. Facility census: 61. Findings include: a) Residents #44, #12, #54, #90, and #27 1. Resident #44 Review of the resident's April 2011 MAR, on 05/17/11, revealed Resident #44 had no bowel movement (BM) for four (4) days, for which the facility failed to initiate the bowel protocol. On 04/06/11, Resident #44 was given a [MEDICATION NAME] suppository after not having a bowel movement for four (4) days. On 04/07/11, Resident #44 was given a fleets enema. Further review of the MAR found, on 04/20/11 Resident #44, was again given a [MEDICATION NAME] rectal suppository for no bowel movement after four (4) days. According to the bowel protocol (which is described below), staff should have administered a 30 cc dose of milk of magnesia (MOM) for a resident who had no BM after three (3) days. -- 2. Resident #12 Review, on 05/17/11, of Resident #12's April 2011 ADL flow sheet identified this resident had no BM from 04/03/11 through 04/06/11 (four (4) days). On 04/06/11, a [MEDICATION NAME] rectal suppository was given. Further review revealed Resident #12 also went from 04/15/11 through 04/20/11 without a BM. The MAR indicated [REDACTED]. According to the May 2011 ADL flow sheet, on 05/12/11, Resident #12 did not have a BM from 05/12/11 through 05/15/11 (four (4) days). A dose of MOM was given on 05/15/11. -- 3. Resident #54 Review, on 05/17/11, of Resident #54's April 2011 ADL flow sheet revealed this resident had no BM for eight (8) days, from 04/10/11 t… | 2016-01-01 |
| 9247 | 9247 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 323 | J | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure that one (1) of twelve (12) Stage II sample residents received the necessary supervision and positioning to prevent choking / aspiration during oral consumption. Resident #14, a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was discovered slumped sideways in his bed at 9:15 a.m. on 05/11/11, with his breakfast tray on an overbed table above his abdomen. His head, right arm, and right shoulder were pressed against the siderail of his bed, with the call bell wedged under his right side between the mattress and siderail. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. Interviews with staff members revealed the resident had experienced an episode of choking earlier the same morning, with staff intervening and repositioning him in the bed. The resident was left unsupervised to continue to eat until discovered by this nurse surveyor. review of the resident's medical record revealed [REDACTED]. Staff was aware he would frequently refuse to get out of bed for meals, and he was evaluated by a speech language pathologist (SLP) to see what could be done to promote safe eating and drinking while in bed. A recommendation was made to have him sitting in an upright position in bed with pillow positioning under his right side to assist him in maintaining this upright position, but this recommendation was not incorporated into the resident's care plan. In fact, his care plan was not revised at all to address his frequent refusals to get out of bed for meals. With regard to the amount of supervision Resident #14 was to receive during meals, the SLP's recommendation for distant supervision was made based on the need to consider the availability of nursing staff… | 2016-01-01 |
| 9248 | 9248 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 328 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and pulse oximeter reading, the facility failed to assure one (1) of twelve (12) Stage II sampled residents received continuous oxygen as ordered by the attending physician. Resident identifier: #30. Facility census: 61. Findings include: a) Resident #30 During random observations of the resident environment on 05/19/11 at 10:15 a.m., Resident #30 was seated in her wheelchair in the middle of the 100 hallway. The resident was noted to have her head tilted back and appeared to be sleeping. Closer observation found the resident displayed an indentation extending from her nares, across her cheek, to her right ear. This type of mark is frequently observed with residents who utilize oxygen via a nasal cannula. No oxygen tank was observed on the back of her wheelchair, nor was any oxygen tubing observed. Review of the resident's medical record found the attending physician ordered the resident to receive oxygen at a rate of 2 liters / minute via nasal cannula continuously for a [DIAGNOSES REDACTED]. This active order was dated 09/13/10. A request was made of the director of nursing (DON - Employee #40 to check the resident's oxygen saturation at 10:18 a.m. on 05/19/11. The DON then asked a licensed practical nurse (LPN - Employee #67) to check the resident's oxygen saturation. Employee #67 obtained a pulse oximeter and checked the resident's oxygen level while the resident was in the dining room. The initial reading on the pulse oximeter was 89%. As the resident was stimulated with conversation, her reading increased to 92%. | 2016-01-01 |
| 9249 | 9249 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 360 | E | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assure seven (7) of sixty (60) residents receiving an oral diet containing an adequate amount of protein for the evening meal; the dietary staff failed to prepare pureed turkey in a manner to assure residents on a pureed diet received 2 ounces of turkey as required by the planned menu. Additionally, the facility failed to assure one (1) of twelve (12) Stage II sample residents was provided the ordered amount of nutritional supplement. Resident identifiers: #29, #44, #46, #55, #63, #66, #83, #90, and #7. Facility census: 61. Findings include: a) Residents #29, #44, #46, #55, #63, #66, #83, and #90 During observations of the evening meal service on 05/16/11, the cook (Employee #61) was observed portioning pureed turkey with a 2 ounce scoop. Review of the menu found residents were to receive a turkey sandwich for dinner. Employee #61 was not observed to serve pureed bread with the pureed diets. When asked why residents did not receive pureed bread, Employee #61 stated he had pureed the turkey and bread together. The dietary manager (Employee #5) was asked, at 4:50 p.m., how much protein residents on pureed diets were to receive. She stated the residents on pureed diets were to receive 2 ounces of pureed turkey. When asked how Employee #61 was providing 2 ounces of turkey when he had pureed turkey and bread together and was utilizing a 2 ounce scoop to serve the combined food items, she agreed the residents were not receiving 2 ounces of turkey and gave Employee #61 a 3 ounce scoop to utilize for service of the pureed turkey / bread mixture to residents on a pureed diet. -- b) Resident #7 During morning medication pass on 05/17/11, the nurse said the resident was to receive 4 ounces of Hi-Cal (a nutritional supplement) as she poured the liquid into a small plastic cup. She poured up to the lowest decorative line on the cup. The same type of cup used during the medication pass was la… | 2016-01-01 |
| 9250 | 9250 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 371 | F | 0 | 1 | UNLT11 | Based on observation and staff interview, the facility failed to assure dietary personnel prepared and distributed food in a sanitary manner. This deficient practice had the potential to affect sixty (60) of sixty-one (61) residents who consumed an oral diet. Facility census: 61. Findings include: a) During the evening meal service on 05/16/11 at 4:20 p.m., observation found a small food bar set-up in the resident dining room. Residents and staff referred to this arrangement as the cafe. Staff members obtained individual plates of food and bowls of soup from the cook for delivery to the residents seated in the dining room. This created a restaurant-like atmosphere. Observation further noted that dietary slips were arranged on a table in front of the food bar. Numerous staff members in the dining room handled the dietary slips with their bare hands. During the service, staff members handed the cook the dietary slips, who would place them on top of the eating surface of a clean plate. The cook would then place food on these contaminated plates for service to the residents in the dining room. Prior to beginning the food service, the cook was observed at 4:20 p.m. on 05/16/11 to enter the cafe area from the resident hallway. Without washing his hands, the cook donned gloves in preparation to begin assembling turkey sandwiches. When asked where he had come from, the cook (Employee #61) stated he had been fixing the handrail in the resident hallway. After this prompting, Employee #61 removed the gloves and washed his hands. Observations of the meal service noted Employee #61 would repeatedly use his gloved hands to pull up the back of his pants and touch other parts of his clothing. He would then use the contaminated gloves to touch white bread, tomato, lettuce, and slices of turkey to assemble the turkey sandwiches being served for the regular consistency diets. When this practice was brought to the attention of the dietary manager (Employee #5), she stated Employee #61 tended to fidget when nervous. -- b) Initial din… | 2016-01-01 |
| 9251 | 9251 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 425 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain medications in a timely manner for administration to two (2) of twelve (12) Stage II sample residents. The facility failed to assure Resident #67 received Ativan 2 mg as prescribed by the attending physician, for treatment of [REDACTED].#7 in a timely manner. Resident identifiers: #67 and #7. Facility census: 61. Findings include: a) Resident #67 Review of Resident #67's medical record found an order by the attending physician written on 05/01/11 for Ativan 2 mg at bedtime for treatment of [REDACTED]. During an interview with a registered nurse (Employee #84) on 05/17/11 at 1:22 p.m., she was asked why the resident missed two (2) doses of Ativan 2 mg after it was ordered by the physician. Employee #84 relayed they did not have a prescription to send to the pharmacy. When asked why the medication was not obtained from the emergency drug box, she stated nursing staff should have contacted the physician and requested they call the pharmacy to provide an access code which would allow the nursing staff to remove this controlled medication from the emergency drug box. -- b) Resident #7 On 05/17/11 at 8:30 a.m., a licensed practical nurse (LPN - Employee #27) was observed administering medications to this resident. During reconciliation of medication pass to this resident on 05/17/11 at approximately 10:50 a.m., it was noted the resident had not received the medication Prilosec that morning. The MAR, when checked to ascertain the time it was scheduled to be given, indicated the medication should have been given during the morning medication pass. At 11:18 a.m., Employee #27 was asked about the Prilosec. She said the resident was out of the medication. She was asked to verify this by checking the medication cart. There was an empty box in the drawer of the medication cart for this resident. Review of the medications available in the emergency medication box found Prilos… | 2016-01-01 |
| 9252 | 9252 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 431 | F | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on inspection of medication storage rooms, the facility had failed to ensure medications and supplies were stored in a safe and orderly manner. Expired medications, improperly stored medications, expired ancillary items, and expired non-medication items were found stored in a disarrayed fashion. This had the potential to affect all residents receiving medications. Facility census: 61. Findings include: a) Medication storage rooms On 05/19/11 at approximately 4:00 p.m., inspection of the medication storage rooms found the following (this list is not all inclusive): -- A gastrostomy tube that was labeled as having been sterile stamped by the manufacturer as Use by [DATE] -- 2 ml Monoject safety syringes that expired 02/2011 -- An open 10 ml vial of bacteriostatic sodium chloride with less than half of the solution remaining was not labeled to indicate when it had been opened -- Two (2) tabs of Lipitor 40 mg were found loose in a drawer -- One (1) bag of mixed meds including Amoxicillin, Cephalexin,Warfarin of various strengths, Cipro 500, Lisinopril 40, Coreg, Bactrim, Lasix- various strengths , Levaquin, Nexium, Chlorpromazine, Clindamycin, etc. There were over fifty (50) pills in the bag. -- A book of Bible Puzzles for Kids -- Four (4) Vacutainers for urine that had an expiration date of 04/2007 -- An IV connecter that expired 11/2009 -- A Micro-tainer that had expired December 1999 -- Seven (7) Vacutainers (purple top) that had passed their expiration dates -- Applicators that had expired 10/10 , 10/08, 12/06 -- An IV start kit that had expired 10/10 -- A contaminated Foley catheter -- IV supplies and urinary catheters were found stored in drawers in a haphazard manner -- Three (3) vials of Influenza Virus Vaccine that were open, with no date to indicate when they were opened. Additionally they were stamped by the manufacturer as expiring 03/31/11 -- One (1) vial of Influenza Virus Vaccine that was opened and dated 11/14/10, that had e… | 2016-01-01 |
| 9253 | 9253 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 441 | F | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility surveillance data, review of hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC), and review of facility policies and procedures, the facility failed develop and implement an infection control program to prevent the development and spread of disease. Surveillance data was not analyzed to determined whether there were trends and / or patterns of infection, employees did not perform handwashing using accepted guidelines, clean gloves were not handled in a manner to prevent contamination before use, the scoop for [MEDICATION NAME] was not stored to prevent contamination of the product, and the tip of the dropper bottle for eye drops was contaminated during medication administration. All residents had the potential to be affected by these practices. Facility census: 61. Findings include: a) Initial dining observation In the main dining room during the evening meal on 05/09/11, two (2) dietary staff (Employees #61 and #72) were observed preparing the meals for the residents at a table in the dining room. Two (2) skillets were being used to prepare grilled cheese sandwiches. Employee #61 was observed handling the grilled cheese with gloved hands. At one point, Resident #58 said she wanted chicken soup, not the tomato soup that was being served. This was communicated to a staff member when she served. The staff member informed Employees #61 and #72 of Resident #58's request. Employee #72 reached under the table with his gloved hand and removed a can of chicken noodle soup. He then handled a grilled cheese sandwich before opening the can of soup. After putting the soup in a bowl and putting it into the microwave behind the table, he returned to the table. He proceeded to handle another grilled cheese sandwich and added Tater Tots to a plate. Both items were handled with the same gloves worn when the soup was opened and microwaved. A few minutes later, Employee #61… | 2016-01-01 |
| 9254 | 9254 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 492 | D | 0 | 1 | UNLT12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and a review of the West Virginia Board of Pharmacy, West Virginia Code of State Rules, the facility failed to comply with the rules set forth by the board of pharmacy related to labeling of medication for one (1) of eight (8) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 On 07/21/11 at approximately 2:00 p.m., the medical record for Resident #21 revealed a physician's orders [REDACTED].) The order, written at 10:00 p.m. on 07/15/11, stated: (symbol for 'change') [MEDICATION NAME] to 66 ml BID (twice per day). The Medication Administration Record [REDACTED]. On 07/22/11 at approximately 3:00 p.m., Employee #76 (registered nurse / nurse practice educator) and Employee #77 (a corporate registered nurse) provided a copy of the label attached to the bottle of [MEDICATION NAME]. The label contained the resident's name as well as the date 07/14/11. The label indicated the following dosage instructions: 22.5 ml by mouth every eight (8) hours. The bottle also identified the contents of the medication as [MEDICATION NAME] 10 gm/15 ml solution. The West Virginia Board of Pharmacy, West Virginia Code of State Rules, states: 19.13.2. To dispense, deliver, or distribute a prescription drug order accurately as prescribed. For the purposes of this paragraph 'accurately as prescribed' means a. To the correct patient (or agent of the patient) for whom the drug or devise was prescribed; b. with the correct drug in the correct strength, quantity, and dosage from ordered by the practitioner; a pharmacist may substitute a generic drug pursuant to W.Va. Code? 30-5-12b; and c. With correct labeling (including directions for use) as ordered by the practitioner. On 07/22/11 at approximately 3:30 p.m., Employees #76 and #77 confirmed the label on the bottle of [MEDICATION NAME] did not accurately reflect the current order by the prescribing practitioner. | 2016-01-01 |
| 9255 | 9255 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 502 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an ordered laboratory test was completed timely. One (1) of twelve (12) Stage II sample residents did not have a metabolic panel completed as ordered after she was found to have a critically low serum potassium level. Resident identifier: #27. Facility census: 61. Findings include: a) Resident #27 A basic metabolic panel (BMP) was ordered on [DATE] to be done in three (3) days. The results of the complete metabolic panel (CMP), completed on 04/18/11, showed the resident had a potassium of 2.4, which was noted to be a critical level (normal 3.5 - 5.2 according to the lab printout). The physician ordered the resident's [MEDICATION NAME] be reduced from 80 mg TID (three (3) times a day) to 80 mg BID (two (2) times a day) and her potassium chloride be increased from 20 mEq in the morning and 40 mEq at night to 40 mEq BID. Review of the medical record, on the mid-afternoon of 05/18/11, did not find the results of the BMP that should have been completed on 04/22/11. Employees #25 (the ward clerk) and #83 (a registered nurse) looked in the physicians' notebooks, reports that needed to be filed, the resident's medical record, and elsewhere. The results could not be located. Employee #83 found the treatment book, where it was indicated the day the BMP was scheduled and the nurse had written REF. The nurse said this meant the resident had refused the test. The nursing entries were reviewed, but there was no mention of the resident's refusal of the lab study. There was no indication the physician had been made aware of the resident's refusal. There was no evidence further attempts were made to collect the needed specimen. | 2016-01-01 |
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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 );