cms_WV
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11539 | 11539 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-09-03 | 520 | J | LWGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staf… | 2014-01-01 | ||
| 11538 | 11538 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-09-03 | 323 | J | LWGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitor… | 2014-01-01 | ||
| 11537 | 11537 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-09-16 | 204 | D | WF8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to provide sufficient preparation at discharge of one (1) of six (6) sampled residents to ensure an orderly transfer from the facility, by failing to safeguard and return timely to the resident and/or responsible party important personal documents left in the facility's possession on admission which could not be produced at the time of the resident's discharge. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #94 During an interview at 3:15 p.m. on 09/13/10, Resident #96's responsible party reported she had not yet received the resident's Medicare benefits card, social security card, or her driver's license, which she had given to staff at the time of the resident's admission to the facility on [DATE]. Resident #96 was discharged from the facility on 08/20/10. The responsible party stated these identification cards were necessary for obtaining health care services for the resident. Review of the resident's closed record revealed a copy of the resident's Medicare benefits card, confirming it had been presented to the facility. There was no mention in the record of the location of the original card. During an interview with the social worker (Employee #8) at 10:40 a.m. on 09/16/10, she acknowledged the cards had not been returned and, in fact, could not be located. She stated she had met with the resident's daughter shortly before her mother's discharge and returned jewelry that had been held for the resident in the facility's safe. At that time, the daughter asked her about the cards. Employee #8 had no knowledge of the cards and had assured the daughter she would locate them and have them returned. She stated this duty had been given to the admissions clerk, who reported she had them in her possession and volunteered to return them. A week ago, the social worker had been contacted again by the resident's daughter, who had again req… | 2014-01-01 | ||
| 11536 | 11536 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 514 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of facility policy, the facility failed to maintain clinical records for each resident that were complete and accurately documented in accordance with facility policy, for one (1) of six (6) sampled residents. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 "Administering Medication" policy (Revised 09/05 and 07/01/06) found Item #12 stated, "Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, "Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times." | 2014-01-01 | ||
| 11535 | 11535 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 281 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and a review of the facility's policy regarding medication administration, the facility failed to ensure that medications were given as ordered by the physician. Resident #59 did not receive Tylenol every six (6) hours for three (3) days as ordered by the attending physician. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 "Administering Medication" policy (Revised 09/05 and 07/01/06) found Item #12 stated, "Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, "Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times." . | 2014-01-01 | ||
| 11534 | 11534 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 157 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, an interview with the family nurse practitioner, and medical record review, the facility failed to notify the health care decision maker for one (1) of six (6) sampled residents after the resident's oral medications were discontinued. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the physician's orders [REDACTED]. Documentation on the physician's orders [REDACTED].#59 of the changes in the resident's medications. This was confirmed by an interview with the FNP and the resident's attending physician at 9:00 a.m. on 09/09/10. The FNP said the medications were discontinued after the FNP had a discussion with the MPOA. She said she told the MPOA she would evaluate the resident's ability to swallow and then decide if she was going to discontinue the oral medications. She said she went into the resident's room, sat the resident up in the bed, and gave the resident a drink of water. This was documented on a progress note written by the FNP on 08/19/10. The 08/19/10 progress note stated: "Chief complaint: F/U (follow-up) CXR (chest x-ray) (8/18/10) and F/U lethargy (8/18). CXR impression with New findings of subtotal collapse of right lung, possibly due to mucous plug or occult [MEDICATION NAME] lesion. "Neuro: Unchanged: lethargic, but will open eyes and speak when stimulated. "Neuro Addendum: Assessed swallowing, sat her up in bed at 90 degrees, tilted head forward, she drank 2 oz, but then coughed. "Impression: Stable chronic Problems: End stage lung CA. Terminal condition. Prognosis Poor. Suspect dysphagia and high risk for aspiration. "Plan: No change in Care Today: Called (Resident #59's MPOA) on her cell phone and updated (Resident #59's) condition. Report CXR results, VS and physical exam findings. Requested [MEDICATION NAME] give for possible 'pneumonia' Advised that [MEDICATION NAME] will probably not change outcome but will order it. (Resident #59's MPOA) stated, 'I… | 2014-01-01 | ||
| 11533 | 11533 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2010-09-28 | 441 | D | QQ4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: "1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10." Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - "F/C patent to leg ..." - On 07/27/10 - "F/C patent to leg drainage bag. Orange urine noted ..." - On 07/28/10 - "F/C patent to drainage on leg bag. Some leakage noticed but good flow ..." - On 07/30/10 - "Cath was removed yesterday R/T (related to) burning and leaking ..." During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/0… | 2014-01-01 | ||
| 11532 | 11532 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-11-03 | 514 | D | GVP312 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure an accurate and complete medical record by failing to transcribe a physician's phone order into the correct locations on the medical record which resulted in confusion during the investigation of a potential medication error in the treatment of [REDACTED]. Resident identifier: #7. Facility census: 113. Findings include: a) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female who received [MEDICATION NAME] daily for control of a [MEDICAL CONDITION] disorder. A recent hospitalization resulted in new medication orders when she was readmitted to the facility. When readmitted on [DATE], the physician ordered: "[MEDICATION NAME] (125 mg/5 ml) 7.5 ml TID (3 times daily) PO (by mouth) and [MEDICATION NAME] 5 ml Q HS (at bedtime) PO." On 09/30/10, these orders were changed. All previous [MEDICATION NAME] orders were discontinued, and the physician ordered: "[MEDICATION NAME] 7.5 ml @ 8:00 a.m.; 5 ml @ 12:00 p.m.; and 7.5 ml @ 4:00 p.m. PO." On 10/21/10, the laboratory results showed a drop in the resident's serum [MEDICATION NAME] level, and when the physician was notified, documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] (125 mg/5 ml) 5ml Q HS PO." There was no evidence in the physician's orders [REDACTED]. During an interview with the nurse (Employee #7) at 2:30 p.m. on 11/02/10, she stated, after reviewing the record, that she was the nurse who had reported the laboratory values to the physician's office and received the new order, which she had placed on the MAR, but she had failed to transcribe the order onto the physician's orders [REDACTED]. | 2014-01-01 | ||
| 11531 | 11531 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-11-03 | 280 | D | GVP312 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and/or revise the comprehensive care plan when the health care status and care needs changed for three (3) of fifteen (15) sampled residents. Resident identifiers: #4, #7, and #11. Facility census: 113. Findings include: a) Resident #4 A review of the medical record revealed Resident #4 was an [AGE] year old female admitted on [DATE] with multiple diagnoses. She was re-hospitalized shortly after admission and readmitted to the facility on [DATE]. Her attending physician ordered "Comfort Measures Only" on 10/15/10, due to a decline in her health care status and the recent [DIAGNOSES REDACTED]. The nursing notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"just wanted to go to sleep". A review of the resident's care plan revealed there were no goals set and no nursing interventions to address the "End of Life Care" needs of this resident. During an interview with one (1) of the assistant director of nurses (ADON - Employee #3) at 2:40 p.m. on 11/02/10, she acknowledged these needs should have been addressed when the "Comfort Measures Only" order was written on 10/15/10. At 3:20 p.m. on 11/02/10, Employee #3 also confirmed there was no care plan revision addressing the resident's "End of Life Care" needs. -- b) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was recently hospitalized and readmitted on [DATE]. On 10/22/10, a suprapubic catheter was placed to aid in the healing of a pressure ulcer on the coccyx, a skin tear of the rectum, and the chronic UTIs. A review of the clinical record, on 11/02/10, failed to find evidence of a revision of the comprehensive care plan to include goals and nursing interventions for the care of the suprapubic catheter. There was also no interim plan of care established. The nursing… | 2014-01-01 | ||
| 11530 | 11530 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 279 | D | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to develop a comprehensive care plan for one (1) of twelve (12) sampled residents describing the services to address all medical and nursing needs that were known to the facility. Resident #115 was admitted to the facility following a hospital stay during which she was treated for [REDACTED]. No care plan was developed to address the need for ensuring the resident maintained adequate hydration status / fluid balance and did not acquire a repeat UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality… | 2014-01-01 | ||
| 11529 | 11529 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 155 | D | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only "comfort measures", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select "comfort measures", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospi… | 2014-01-01 | ||
| 11528 | 11528 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 225 | E | GVP311 | . Based on record review and staff interviews, the facility did not ensure that four (4) of eight (8) resident concern forms reviewed, containing allegations of resident abuse / neglect involving nursing assistants, were reported to the State nurse aide registry. Resident identifiers: #115, #116, #117, and #20. Facility census: 114. Findings include: a) A review of the facility's complaint file revealed four (4) resident concern forms containing allegations of resident abuse / neglect which involved nursing assistants. These allegations of abuse / neglect were reported to the facility by family members and residents as follows: 1. A concern form, dated 07/20/10, stated the medical power of attorney representative (MPOA) of Resident #115 reported finding the resident lying wet with food on her clothes. 2. A concern form, dated 08/21/10, stated Resident #116 "stated she wanted to use BSC (bedside commode) but was told by 11-7 (night shift staff) that she needed to use the bedpan - 'that it's our protocol'. When she used the bedpan, the bed got wet. Res (resident) states only the top sheet was changed & the fitted sheet was still wet. When she told the CNA (certified nursing assistant) the bottom sheet was still wet, res says CNA said 'It's not wet unless you peed again' then (symbol for 'checked') the sheet & told res is was dry. Later res says she was cold & asked for a blanket. States CNA took her temp (97.1) & was told she 'didn't need a blanket.' Res was upset enough to tell (name of nurse) that she was ready to sign out AMA (against medical advice) the next morning. ..." 3. A concern form, dated 08/21/10, stated, "... Res (Resident #117) said 'I'm not one to complain' then hesitated. When asked what the problem was, he said 'You know. Night shift.' I asked what happened. Res stated 'When I had my light on, they came in & said 'What do you want now.' Res inferred it was said in a (sic) unpleasant tone of voice. Res then said CNA turned off the light & left the room." 4. A concern form, dated 07/15/10, stated, "… | 2014-01-01 | ||
| 11527 | 11527 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 157 | D | GVP311 | . Based on record review and staff interview, the facility failed, for one (1) of twelve (12) sampled residents, to notify the resident's medical power of attorney representative (MPOA) and attending physician when the status of the resident's pressure sore significantly declined. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 A review of the facility's weekly skin report for Resident #115, dated 08/04/10, found: "The coccyx measurement is not able to be staged." The pressure sore was described as measuring 7 cm x 7 cm x less than 0.8 cm with eschar. This was a significant change from the previous week when, on 07/28/10, the pressure sore on the resident's coccyx measured 2.8 cm x 0.7 cm x 0.3 cm and no eschar was present. A review of nursing notes, on 08/04/10, did not find evidence to reflect either the physician or the resident's MPOA was notified of this significant decline in status of the resident's pressure sore. An interview with the wound care nurse (a registered nurse - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when on 08/04/10 the resident's pressure sore was assessed to be larger and was not able to be staged due to the eschar, she did not call the physician or notify the MPOA. . | 2014-01-01 | ||
| 11526 | 11526 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 309 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide care and services necessary to attain or maintain the highest practical level of physical well-being for one (1) of twelve (12) sampled residents. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, severe dehydration, and an infected pressure sore. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in her hydration status, quantity and quality of her urinary output, and/or presence of signs / symptoms of UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED… | 2014-01-01 | ||
| 11525 | 11525 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 327 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... " According to a Transfer Summary Report hemodynamically stable". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also… | 2014-01-01 | ||
| 11524 | 11524 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 314 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was "large and foul-smelling" and the odor was "overpowering"; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further worku… | 2014-01-01 | ||
| 11523 | 11523 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 364 | E | 9G3Y11 | . Based on observation, resident interview, and staff interview, the facility failed to assure the evening meal served on 09/08/10 was prepared in a manner that assured the food was palatable and attractive. This deficient practice affected more than an isolated number of residents receiving an oral diet. Facility census: 118. Findings include: a) Random observation of the evening meal, on 09/08/10, noted residents were served two (2) mounds of a grey-white gelatinous substance containing green flecks. It was noted that none of the residents eating in their rooms consumed the substance. When asked how the evening meal tasted, a resident (who wished to remain anonymous) described the taste as "Yucky". Another resident stated that it smelled like dog food. An interview with the dietary manager (Employee #16) was conducted at 6:25 p.m. on 09/08/10. When inquiry was made as to what the two (2) mounds of green-flecked substance served to residents were, she stated, "Turkey Tetrazzini." She stated the broccoli was overcooked due to the cook having to take her test and not getting back in time. She agreed the meal did not smell or look appetizing. . | 2014-01-01 | ||
| 11522 | 11522 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 241 | D | 9G3Y11 | . Based on observation, the facility failed to assure one (1) of eight sampled residents (Resident #96) was provided care in a manner that maintained her dignity while being transported through the hallway to the shower. Resident identifier: #96. Facility census: 118. Finding include: a) Resident #96 Random observations of the facility, on 09/08/10 at 4:10 p.m., found a staff member transporting Resident #96 through the hallway on a shower chair. The resident was seated on a commode-seat type shower chair. The staff member had placed a sheet around the top of the resident but failed to assure the resident's bottom was covered. The resident's unclothed buttocks were visible beneath the chair as the staff member pushed her down the hallway. This practice was brought to the attention of the unit manager (Employee #53), who obtained a sheet from the clean linen cart in the hallway and assured the resident was adequately covered. . | 2014-01-01 | ||
| 11521 | 11521 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 242 | D | 9G3Y11 | . Based on review of resident council minutes and staff interview, the facility failed to assure one (1) random resident with a sample of eight (8) residents was afforded the right to choose bathing schedules consistent with aspects of his life in the facility that were significant to him. Resident identifier: #25. Facility census: 118. Findings include: a) Resident #25 Review of resident council minutes for 06/23/10 found Resident #25 requested that he be provided showers three (3) times a week. The response from the facility stated, "Not staffed for 3 showers per week." Under discussion of old business for the 07/26/10 resident council meeting, the minutes documented, "We are not staffed to give residents 3 showers a week." An interview with the administrator, on 09/09/10 at 9:10 a.m., revealed the wishes of the resident should have been honored. . | 2014-01-01 | ||
| 11520 | 11520 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 514 | D | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to maintain the medical record of one (1) of eight (8) sampled residents in accordance with accepted professional standards and practices. Resident #81 sustained a fall resulting in a [MEDICAL CONDITION], but her medical record contained no progress note entries addressing the fall or the resident's subsequent hospitalization . Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found Resident #81 sustained a fall from her bed on 08/22/10 and suffered a [MEDICAL CONDITION] requiring surgical repair. Review of the medical record found no nursing progress note or other documentation of the resident's fall and subsequent transfer to the hospital. An interview with the director of nursing (DON - Employee #10), on 09/10/10 at 4:00 p.m., confirmed the medical record did not contain progress notes or any other documentation of the resident's fall and subsequent transfer to the hospital on [DATE]. | 2014-01-01 | ||
| 11519 | 11519 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 224 | G | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to ensure that goods and services were provided to prevent physical harm to one (1) of eight (8) sampled residents. Facility staff failed to assure that physician-ordered landing strips (utilized to pad / cushion the floor) were placed beside Resident #81's bed and failed to assure her bed was in a low position when left unattended on 08/22/10. Resident #81 fell from the bed and sustained a [MEDICAL CONDITION] requiring surgical repair. The graduate nursing assistant (Employee #136) responsible for the resident's care on 08/22/10 denied having knowledge of the requirement to place landing strips beside the resident's bed. The facility failed to put into place a system to orient new employees and temporary agency staff to the planned / ordered interventions to be provided to each resident. Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 fell from her bed to the floor. Facility staff documented the resident's bed was in a high to knee-high position with no physician-ordered landing strips present to cushion the floor beside the resident's bed. The resident sustained [REDACTED]. Review of the medical record found an active physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/10, found the resident was assessed as being severely cognitively impaired with impaired long and short term memory, and she required the extensive physical assistance of one (1) staff member for bed mobility, transfers, dressing eating, toilet use, and personal hygiene. The assessor also noted resident had sustained a fall in the thirty (30) days prior to the ARD. - Further review of facility information, concerning Resident #81's fall from bed on 08/22/10, found Employee #136 stated … | 2014-01-01 | ||
| 11518 | 11518 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 225 | D | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, review of facility documents, and staff interview, the facility failed to ensure two (2) of two (2) allegations of neglect / abuse were reported immediately to the State survey and certification agency and other officials in accordance with State law, and failed to thoroughly investigate the allegations of neglect / abuse. It was further determined that, due to the failure of the facility to report and investigate allegations appropriately, the facility failed to take appropriate corrective actions. The facility failed to immediately report one (1) allegation of neglect, when a staff member failed to assure Resident #81's bed was placed in the low position with landing strips (utilized to pad the floor) placed beside the resident's bed prior to leaving the resident unattended, in accordance with the resident's physician orders. The resident fell from her bed and sustained a [MEDICAL CONDITION] which required surgical repair. The facility did not report this allegation until three (3) days after the incident. The facility failed to report, investigate, or take appropriate corrective actions when Residents #117 and #52 made complaints to facility staff concerning Employee #5 on 08/26/10, and requested that she no longer provide care for them. Resident identifiers: #81, #117, and #52. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 was found on the floor of her room. The resident's bed was left in a high position with no ordered landing strips placed on the floor beside her bed. The resident was subsequently hospitalized with a [MEDICAL CONDITION] which required surgical repair. Further review of facility documents found the graduate nursing assistant (Employee #136), who had been assigned to provide care for the resident on the day of the fall, claimed to be unaware that the resident was to have landing strips beside her bed. R… | 2014-01-01 | ||
| 11517 | 11517 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 387 | D | XJ0U13 | **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 ten (10) sample residents received a physician visit in the facility at least once every thirty (30) days for the first ninety (90) days after admission. This resident, who resided in the facility from [DATE] until 12/17/10, had no face-to-face visits with his attending physician. Resident #143. Facility census: 142. Findings include: a) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, "This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file." . | 2014-01-01 | ||
| 11516 | 11516 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 501 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's medical director failed to assume responsibility for the coordination of facility-wide medical care. There was no evidence of ongoing collaboration by the medical director with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct continuing non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care. Additionally, the medical director failed to coordinate medical care by not assuring Resident #143 received timely physician visits, and failed to assume the care of Resident #152 when nursing staff contacted him for medication for the resident, instructing staff to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. These practices affected two (2) of ten (10) sample residents during the current survey and had the potential to result in more than minimal harm to more than an isolated number of facility residents. Resident identifiers: #152 and #143. Facility census: 142. Findings include: a) The facility has had continued non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care (F309) during the last three (3) survey events at the facility, beginning with a survey event that concluded on 09/01/10, resulting in findings of deficiencies in quality of care at a level of harm. There was no evidence of ongoing collaboration with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct this continuing non-compliance. (See also citation at F309.) - b) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending p… | 2014-01-01 | ||
| 11515 | 11515 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 441 | D | XJ0U13 | . Based on random observation and staff interview, the facility failed to implement an infection control program which effectively helped prevent the potential spread of disease and infection in the facility. A staff member was observed to rinse a bed pan soiled with urine in the sink in a resident's bathroom. This same staff member also obtained drinking water from other sinks to fill residents' water pitchers. This was true for one (1) of ten (10) sampled resident. Resident identifier #105. Facility census: 142. Findings include: a) Resident #105 At approximately 11:30 a.m. on 01/04/11, Employee #33 was observed to assist Resident #105 off a bedpan. The NA (nursing assistant) emptied the urine from the bedpan into the toilet located in the resident's room. The NA then turned on the water in the resident's sink and rinsed the bedpan. This nursing assistant was previously observed filling Resident ' s water pitchers at others sinks. The NA, who was interviewed immediately following the observation, was asked what she thought about rinsing bedpans from the same sink that drinking water was obtained. The NA stated it was "gross" because the "urine splashes up". . | 2014-01-01 | ||
| 11514 | 11514 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 281 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of "Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses" (revised 06/17/09), and medical record review, the facility failed to provide goods and services in accordance with professional standards of quality, by assigning a licensed practical nurse (LPN) to complete in-depth skin assessments (including making a determination regarding the staging of pressure ulcers), an act outside her scope of practice. This practice affected one (1) of ten (10) sampled residents (#145) with the potential to affect all residents with pressure sores. The facility also failed to assure that physician orders [REDACTED]. This practice affected one (1) of ten (10) sampled residents (#152) with the potential to affect any other resident with similar physician orders. Resident identifiers: #145 and #152. Facility census: 142. Findings include: a) Resident #145 1. An interview was conducted, on 01/06/11 at 3:40 p.m., with registered nurse (RN - Employee #187) related to the care and services provided to promote healing to former Resident #145. During this interview, Employee #187 requested the assistance of the wound nurse, Employee #127 (who was an LPN). While discussing the interventions that had been put into place for Resident #145, Employee #127 described her contribution to the assessment of pressure ulcers. The LPN reported, at 3:55 p.m. on 01/06/11, that she was responsible for all the pressure ulcers of residents on the A, B, and C units of the facility. She stated she measured the wound beds; identified / described the presence of any tunneling, drainage, and colors; and staged the wounds. When asked if she had received specialized training in the assessment and staging of wounds, Employee #127 stated she did not have any additional credentials such as a wound care specialist. - 2. The administrator was asked, on the afterno… | 2014-01-01 | ||
| 11513 | 11513 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 353 | E | XJ0U11 | . Based on record review, resident interview, and staff interview, the facility failed to deploy sufficient direct care staff across all shifts and units to ensure residents received personal hygiene as needed and as planned by the facility. Record review revealed two (2) of four (4) residents (#43 and #66) residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. When interviewed, Resident #43 reported she wanted her showers but sometimes did not get them because staff was too busy. In confidential interviews, nursing assistants on both the 7:00 a.m. to 3:00 p.m. (7-3) shift and the 3:00 p.m. to 11:00 p.m. (3-11) shift reported they have not been able to complete showers as scheduled in the past month or obtain the assistance of a second staff member for turning and repositioning residents who were assessed as requiring the assistance of two (2) for bed mobility due to a lack of availability of staff. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 … | 2014-01-01 | ||
| 11512 | 11512 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 312 | E | XJ0U11 | . Based on record review, resident interview, and staff interview, the facility failed to assure residents were provided personal hygiene as needed and as planned by the facility. Each resident had scheduled shower days twice weekly. Residents were randomly selected for review from each of four (4) halls and equally from 7-3 and 3-11 shifts. Two (2) of four (4) residents residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. These findings excluded any showers offered but refused by residents and marked on the ADL (activities of daily living) sheets as refused. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possi… | 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 11504 | 11504 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2010-09-23 | 311 | E | 5AUJ11 | . Based on record review and staff interview, the facility failed to provide daily restorative nursing services for residents designated to receives those services. Record review revealed specific written plans to meet specific goals for residents in the restorative nursing program. However, restorative aides were, at times, pulled to work the floor in the capacity of a nursing assistant due to staffing shortages, leaving the restorative nursing services undone. During interviews with certified nursing assistants (CNAs) conducted on 09/22/10, seven (7) of eight (8) CNAs interviewed reported they do not follow the restorative nursing plan; rather, they perform range of motion to restorative residents the same as they do to all dependent residents during the performance of activities of daily living. Resident identifiers: #10, #12, #49, #56, #57, #59, #61, #65, #70, #73, #77 #81, and #82. Facility census: 101. Findings include: a) Resident #10 Review of the Restorative Nursing Program (RNP) Flow Sheet, found in the restorative book for September 2010, revealed he was to "perform active assist range of motion (ROM), bilat (bilateral) upper ext (extremities) all joints 3 sets of 20 (twenty) reps (repetitions) daily." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - b) Resident #12 Review of the RNP Flow Sheet for September 2010 revealed Resident #12 was to receive "Active ROM (range of motion) ex (exercise) 2 sets 15 reps (repetitions) in seated position (heel / toe raises, seated marches, knee extension / flexion, hip abduction / adduction) daily". Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/7, 9/8, 9/9, 9/10, 9/12, 9/13/, 9/14, 9/15, 9/16). Resident #12 was also to "Ambulate /c (with) rolling walker - contact guard of 1 assist to daily tolerance / distance." Restorative staff documented having provided this service on o… | 2014-01-01 | ||
| 11503 | 11503 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 285 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to assure a reassessment was completed for a resident who was approved for nursing facility placement for less than three (3) months and remained in residence after six (6) months. Resident identifier: Resident #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. Documentation found on page 5 of 6 of form PAS2000 for this resident disclosed, in Section #38 titled "Physician Recommendation", a nursing facility stay of less than three (3) months had been determined necessary for this resident. The resident had been at the facility for nearly six (6) months at that time. The facility's social worker (Employee #27), when interviewed on 04/25/11 at 1:15 p.m. following a review of the resident's record, confirmed the resident had not undergone reassessment, and the form PAS2000 had not been resubmitted following the initially approved three (3) month period. . | 2014-01-01 | ||
| 11502 | 11502 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 323 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, observation, and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to care plan and/or implement measures to promote safety related to falls. Resident #21 was admitted to the facility on [DATE], after having been hospitalized for [REDACTED]. Interventions to promote safety related to falls were not addressed in her care plan until two (2) months after her admission, when the physician ordered a bed alarm on 12/28/10. Additional interventions (to include placing the resident's bed in a low position) were not added to the resident's care plan until the resident sustained [REDACTED]. When observed on 04/26/11, Resident #21 was observed to be asleep in her bed, but her bed was not in the low position as care planned. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained "multiple bilateral lower extremity fractures". The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and "yelled for help" … | 2014-01-01 | ||
| 11501 | 11501 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 280 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to revise the care plans of two (2) of forty (40) Stage II sample residents, when changes occurred in their health condition and/or treatment plan. Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. The resident's right leg was severely contracted, which caused the resident's right heel to push into the resident's buttocks. The staff had been applying heel protectors to the resident's heels to reduce pressure to these areas; the heel protectors were discontinued on 02/10/11, with no other intervention(s) added to address this unrelieved pressure against the right heel. The pressure on the heel from constant contact with buttocks resulted in a suspected deep tissue injury, which was identified on 04/03/11. At that time, the facility failed to identify this constant pressure as the cause of the pressure sore, and failed to revise her care plan to include measures to reduce / relieve this pressure until after the physical therapist was consulted on 04/19/11. Resident #41's care plan was not revised to reflect the application of a hand roll to address contractures of the resident's left hand. Facility census: 77. Findings include: a) Resident #28 Record review revealed Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. A review of Resident #28's minimum data set assessment (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 01/18/11, revealed the assessor identified, in Section G, that Resident #28 was totally dependent on staff for the performance of all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. In Section K, the assessor noted she did not have a significant weight loss either in the previou… | 2014-01-01 | ||
| 11500 | 11500 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 279 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to develop a care plan to include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident #21 was admitted for a planned short rehabilitation stay and remained in the facility after rehabilitation goals had been met. No care plan was implemented to address the resident's discharge needs. The resident also was known to be at risk for falls at the time of admission, and no care plan goals and interventions were developed to address the risk. The resident did incur additional falls. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 1. When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained "multiple bilateral lower extremity fractures". Review of the physician's determination of capacity for this resident divulged that, at the time of admission (10/26/10), the resident's attending physician determined she did not have the capacity to understand and make health care decisions. This determination was changed on 01/03/11, when it was determined at that time that she did possess the capacity to make those decisions. An entry in social service (SS) notes, dated 11/09/10, stated: "D/C (discharge) plans are to return home." Again on 11/24/10, a SS note stated: "D/c plans remain to return home. No d/c date at this time." On 01/17/11, a SS note stated: "She plans to rehab & return home. MPOA (medical power of attorney) states resident will be LTC (long term care)." One (1) of two (2) minimum data set assessment (MDS) coordinators (Employee #65), when questioned on 04/25/11 at approximately 11:00 a.m. about the resident's pla… | 2014-01-01 | ||
| 11499 | 11499 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 160 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to convey the funds, and a final accounting of those funds, within thirty (30) days after the death of the resident for two (2) of three (3) residents reviewed. Resident identifiers: #60 and #48. Facility census: 77. Findings include: a) Residents #60 and #48 The facility's resident funds accounts were reviewed at 8:30 a.m. on [DATE]. The balance of personal funds being held by the facility for two (2) of three (3) deceased residents reviewed had not been released within thirty (30) days after their deaths as required. Resident #60 passed away on [DATE]. Facility records show the balance of her personal account of $34.30 was not released until [DATE]. Resident #48 passed away on [DATE]. Facility records show the balance of her personal funds of $50.00 was not released until [DATE]. During an interview with the administrator (Employee #36) on [DATE] at 9:20 a.m., she confirmed these funds had not been conveyed within the required thirty (30) days. . | 2014-01-01 | ||
| 11498 | 11498 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-12-02 | 431 | B | 50Z112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, "They rub it on me," while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, "No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use...". | 2014-02-01 | ||
| 11497 | 11497 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 323 | D | 50Z111 | . Based on random observation and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as is possible. A nurse left a 50 cc bottle of liquid Dilantin on top of her medication cart, and left the cart parked and unsupervised at the unlocked nursing station. Resident #68 was observed to have unfettered access to the medication for approximately five (5) minutes. Facility census: 81. Findings include: a) Resident #68 Observations of the resident environment, on 10/06/10 at 8:08 p.m., noted Resident #68 wandering the resident hallway. She was observed to enter the unlocked nursing station and approach the medication cart parked there. No staff members were visible in the hallway or at the nursing station. The resident was approached and an attempt was made to redirect the resident's attention away from a bottle of medication sitting on top of the cart. The resident made inappropriate answers to questions but followed this surveyor out of the nursing station. After approximately five (5) minutes, a nurse was observed to exit a resident's room with a treatment cart. She was informed that Resident #68 was found unsupervised in the nursing station where a bottle of liquid medication was noted to be sitting on top of a medication cart. When asked what the medication was, the nurse (Employee #168) stated the bottle contained 50 cc of Dilantin 125/5ml. She stated she had not been given a key to the medication room to secure the medication. . | 2014-02-01 | ||
| 11496 | 11496 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 493 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timel… | 2014-02-01 | ||
| 11495 | 11495 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 224 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled "Heating back up plan" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted… | 2014-02-01 | ||
| 11494 | 11494 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 257 | F | 50Z111 | . Based on observation, staff interviews, measuring of ambient air temperatures, and information from the National Weather Service, the facility failed to maintain comfortable and safe temperatures (between 71 and 81 degrees Fahrenheit (F)) throughout the building to minimize the risk of hypothermia. Ambient air temperatures in occupied resident rooms, measured in the presence of facility staff, were found to be below 65 degrees F. This deficient practice presented the potential for more than minimal harm to all residents in the facility and constitutes a finding of substandard quality of care. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/05/10 between 5:30 a.m. and 6:35 a.m., were as follows: B333 - 71 degrees F; B331 - 65 degrees F; B329 - 62 degrees F; B327 - 62 degrees F; B325 - 66 degrees F; B323 - 67 … | 2014-02-01 | ||
| 11493 | 11493 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 456 | F | 50Z111 | . Based on observation, staff interview, and measurements of ambient room air temperatures, the facility failed to maintain heating boilers in a safe operating condition. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. At the time of this interview, the administrator and maintenance director related a plan for the installation of a temporarily heating boiler for use during the winter until permanent repair / replacement of the existing heating boiler system could be implemented. This process would take approximately three (3) weeks, during which the facility had to solicit competitive bids for a temporary heating boiler before a contract could be awarded to a outside vendor for installation. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied residen… | 2014-02-01 | ||
| 11492 | 11492 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 517 | F | 50Z111 | . NFPA 101 Life Safety Code 2000 Edition Chapter 19 Existing Health Care Occupancies 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire - NFPA 99 Standard for Health Care Facilities 1999 Edition Chapter 11 Health Care Emergency Preparedness 11-2 Purpose. The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan. 11-4.2 Senior Management. It shall be the responsibility of the senior management to provide its staff with plans necessary to respond to a disaster or an emergency. Senior management shall appoint an emergency preparedness committee, as appropriate, with the authority for writing, implementing, exercising, and evaluating the emergency preparedness plan. This standard is not met as evidenced by: Based on review of the facility's disaster and emergency evacuation plan, the facility did not have a detailed … | 2014-02-01 | ||
| 11491 | 11491 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 313 | D | UFEY11 | Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to "see all the time". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, "I don't hear well." After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, "Resident noted to refuse to interact with staff members for brief p… | 2014-02-01 | ||
| 11490 | 11490 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 225 | D | UFEY11 | Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, "the aids (sic) hurt her legs and were rough with her". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There … | 2014-02-01 | ||
| 11489 | 11489 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 520 | E | UFEY11 | Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well a… | 2014-02-01 | ||
| 11488 | 11488 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 329 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation … | 2014-02-01 | ||
| 11487 | 11487 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 285 | D | UFEY11 | Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. . | 2014-02-01 | ||
| 11486 | 11486 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 221 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as "enablers" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan … | 2014-02-01 | ||
| 11485 | 11485 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 164 | E | UFEY11 | Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the sh… | 2014-02-01 | ||
| 11484 | 11484 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 328 | E | UFEY11 | Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: "Label nasal cannula (also humidifier) with resident name, date, and liter flow." Review o… | 2014-02-01 | ||
| 11483 | 11483 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 441 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing.… | 2014-02-01 | ||
| 11482 | 11482 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 371 | F | UFEY11 | Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. . | 2014-02-01 | ||
| 11481 | 11481 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 309 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an "as needed" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her "pain medications are scheduled". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, "Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). " Another note, dated 01/01/09 at 4:35 a.m., stated, "Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time." A nursing note, dated 01/01/09 at 1:35 p.m., stated, "Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor." There was no evidence of furthe… | 2014-02-01 | ||
| 11480 | 11480 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 279 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: "Refer to the physical restraint / enabler assessment." 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, "Refer to the physical restraint / enabler assessment." The goal associated with this problem was "(Resident) will be free of negative effects with the use of an enabler." This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with freq… | 2014-02-01 | ||
| 11479 | 11479 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 278 | B | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/0… | 2014-02-01 | ||
| 11478 | 11478 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2010-10-06 | 285 | D | 4XPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the WV Medicaid program manual for nursing facilities, the facility failed to coordinate their assessments with the preadmission screening and resident review (PASRR) program under Medicaid as required. The facility readmitted a resident from an inpatient psychiatric stay prior to receiving approval by the State-designated reviewing agency - West Virginia Medical Institute (WVMI), which resulted in the resident having no payer source to cover his continued stay at the facility when it was determined by WVMI that he was no longer medical eligible for nursing home placement under WV Medicaid criteria. Resident identifier: #56. Facility census: 112. Findings include: a) Resident #56 Record review revealed Resident #56 came to the facility on [DATE] with a pre-admission screening form (PAS-2000) signed by the physician on 01/18/10, who indicated his primary [DIAGNOSES REDACTED]. This PAS-2000 was reviewed by WVMI on 01/20/10, at which time the reviewer determined Resident #56 was medically eligible, under the WV Medicaid criteria, for nursing facility services and that a Level II evaluation was necessary. A Level II evaluator determined Resident #56 did not require specialized services for mental illness or mental [MEDICAL CONDITION] on 01/22/10. Resident #56's initial PAS-2000 indicated he was appropriate for nursing home placement for a period of up to six (6) months, after which another PAS-2000 would have to be completed for his nursing home stay to continue to be paid for by WV Medicaid. During this six-month period, Resident #56 was admitted for inpatient psychiatric services from 05/28/10 until 06/09/10, when he was readmitted to the nursing home. A second PAS-2000, signed by a physician on 06/15/10, indicated Resident #56 needed nursing home services and was not likely to eventually return home. On 06/17/10, a reviewer from WVMI denied the request for nursing home admission … | 2014-02-01 | ||
| 11477 | 11477 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-10-14 | 280 | D | LTYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to addr… | 2014-02-01 | ||
| 11476 | 11476 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-10-14 | 164 | E | S21C11 | . Based on observation, staff interview, and a confidential resident group interview, the facility failed to ensure resident privacy was maintained during showers. The men's and women's shower rooms shared a common whirlpool area, and the privacy curtains separating these areas could not be pulled closed to ensure privacy during bathing. This had the potential to affect any resident showered in the central shower rooms at the facility. Facility census: 56. Findings include: a) During a tour of the facility on 10/13/10 at 2:00 p.m., the men's and women's shower rooms were visited by two (2) health facility surveyors. The doors to the shower rooms were separate, but once inside the shower rooms, the men's and women's rooms were connected via a common whirlpool area with full visual access from either side. There were tracks for two (2) sets of privacy curtains, one (1) on either side of the whirl pool area. The only side that had privacy curtains was located on the women's side, and one (1) of the surveyors was unable to pull closed the privacy curtains on this side. The privacy curtains were observed with the facility's administrator at 2:05 p.m. with both surveyors present. The administrator reported that men and women were not showered at the same time. Two (2) nursing assistants (Employees #7 and #54), whom the administrator indicated were shower aides for that day, were interviewed. They indicated they showered about thirty (30) residents on that particular day and finished before noon. They said they did not shower men and women at the same time. During a resident group interview on 10/14/10 at approximately 3:00 p.m., two (2) of four (4) female residents in the group reported they were given showers within the past week while men were in the common shower area at the same time. They reported the privacy curtains could not be pulled all the way closed in order to prevent others from observing while they are taking a shower. They also reported they were able to see the male residents in the shower. This was co… | 2014-02-01 | ||
| 11475 | 11475 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 280 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed, for one (1) of ten (10) sampled residents, to revise the resident's care plan to address her self-administration of aerosolized medications after an order was received from her physician to permit this. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's orders [REDACTED]." An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's care… | 2014-02-01 | ||
| 11474 | 11474 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 328 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure one (1) of ten (10) sampled residents received the maximum benefit of each aerosolized treatment ordered by her physician. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's order permitting her to self-administer the aerosolized treatments; however, there was no evidence the interdisciplinary team completed an assessment to ensure the resident was capable of reliably self-administering these treatments, and this self-administration of aerosolized medications was not addressed on her care plan. Licensed nursing staff was aware Resident #111 did not self-administer these treatments in an effective manner, and they did not provide additional monitoring / supervision to ensure she received the maximum benefit of each treatment. Additionally, licensed nursing staff did not complete pre- and post-treatment assessments that would allow them to determine whether the treatments were effective. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the med… | 2014-02-01 | ||
| 11473 | 11473 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-21 | 309 | D | 6HW411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to monitor the effectiveness of treatment after administration of Tylenol for a new development of fever and in the presence of other symptoms and complaints; the facility also failed to monitor the temperature of a dependent resident with a history of repeated urinary tract infections after a new onset of fever early in the morning. This was evident for one (1) of six (6) sampled residents. Resident identifier: #51. Facility census: 120. Findings include: a) Resident #51 During an interview via telephone on 10/18/10, Resident #51's family member stated that, on 01/10/10 Resident #51 developed a high fever and was medicated with a fever-reducing medication, and five (5) hours elapsed before his temperature was re-checked by staff. By this time, he was totally unresponsive and the fever had elevated even more. Subsequently, he was transported to the hospital for a twelve (12) day stay. Upon his return to the facility, the pressure ulcer on his coccyx had worsened to a Stage IV wound, and he required a wound VAC after the area was surgically debrided during the hospitalization . Medical record review revealed Resident #51's temperature was 100.9 degrees Fahrenheit (F) on 01/10/10 at 3:30 p.m., and he was medicated with [MEDICATION NAME]. The physician was notified, and new orders were received for a urinalysis and culture to be obtained the following day. Further medical record review revealed that, at 5:30 p.m. on 01/01/10, he refused dinner and complained of not feeling well. The nurse documented his refusal to go to the emergency room . There was no evidence that his temperature was monitored at this time, to ascertain whether the [MEDICATION NAME] was effective in reducing his temperature, and there was not evidence to reflect the family was notified of the fever. It was not until 8:00 p.m. on 01/01/10 that the nurse again assessed him again; she do… | 2014-02-01 | ||
| 11472 | 11472 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-21 | 253 | D | 6HW411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, family interview, and staff interview, the facility failed to clean the floor adequately for one (1) of eight (8) sampled residents. Numerous observations of the resident's floor found it to be sticky, even after having been recently mopped. This stickiness had the potential to affect the steadiness of the gait of the resident who was known to ambulate within the room independently; it also compromised safety of others, as it had the potential to harbor bacteria that could be transmitted throughout the facility on the soles of shoes of all staff who entered the room. Resident identifier: #61. Facility census: 120. Findings include: a) Resident #61 Record review revealed Resident #61's [DIAGNOSES REDACTED]. During interview with the nurse unit manager (Employee #51) on 10/19/10 at 4:30 p.m., she said Resident #61's physician orders [REDACTED]. Resident #61 experienced a fall in early October, but x-rays completed af the emergency room ruled out any new fractures; she was wearing hipsters at the time of the fall. Currently, she was on the waiting list for inpatient care at a behavioral health / medicine center related to problem behaviors that were not able to successfully be redirected. Observation of the resident throughout the survey found she walked in her room independently, ambulated to the toilet independently, and was observed closing the door to the hallway on more than one (1) occasion. Observation of the resident's floor, on 10/18/10 at 3:00 p.m., revealed the floor was sticky in a wide area around all sides of the bed. The sticky floor was also observed by the life-safety code (LSC) surveyor who brought it to the attention of Employee #133 (the environmental service director), who immediately called staff to mop the floor. Observation, on 10/18/10 at 5:30 p.m., found the floor had dried and was just as sticky as it had been previously. Observation of the floor, on 10/19/10 at 9:00 a.m., found t… | 2014-02-01 | ||
| 11471 | 11471 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-04 | 166 | D | PYV111 | . Based on a review of the resident council minutes, medical record review, resident interview, family interview, and staff interview, the facility did not ensure all complaints made by residents, families, or responsible parties were documented and investigated. In addition, the facility did not follow up with those individuals making the complaints, to let them know the outcome of the complaint investigation and the resolution to the issue. Resident identifier: #66. Facility census: 120. Findings include: a) Resident #66 During tour of the facility on 10/03/10, a family interview revealed Resident #66 had experienced some problems with having to sit in a soiled brief for a long period of time. The resident had wanted to attend a church service but had to wait for a long time before she could go, because staff was not available to change her soiled brief. On 10/04/10 at approximately 9:00 a.m., telephone contact with Resident #66's family revealed this incident took place in September 2010. The family member indicated there were problems with getting assistance from nurse aides on the last two (2) Sundays in September. The family member reported nurse aides told her they could not assist in changing Resident #66's brief until the lunch trays were picked up. The family member related that, on 09/19/10, she had complained to staff but did not put her complaint in writing. On 09/26/10, she did write a letter listing her concerns about staff not assisting Resident #66 with incontinence care. The family member put the letter under the administrator's door. The administrator confirmed this did occur and that he passed the letter along to Employee #50, the unit manager on the hall where Resident #66 lives. In an interview on 10/04/10 at approximately 11:00 a.m., Employee #50 (registered nurse unit manager) confirmed she had received this letter from the administrator. She said she investigated the family's concerns. The outcome of the investigation did reveal a nurse aide had told the family member she could not assist… | 2014-02-01 | ||
| 11470 | 11470 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-10-07 | 312 | D | UP4G11 | . Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure staff provided necessary assistance to maintain good grooming and personal hygiene for (1) of four (4) sampled residents who was unable to do so for herself. Resident #134 did not always receive mouth care, which she was unable to do for herself. The resident expressed that she would like to get out of bed for short periods of time but was not able to get out of bed by herself and was not gotten up by staff. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 1. Observations made with a licensed practical nurse (LPN - Employee #132) and a nursing assistant (NA - Employee #17), on 10/07/10 at 10:30 a.m., found the resident's teeth had food debris on them. The resident, when interviewed, reported she had not received mouth care that day or on other days on a regular basis. She stated she had her own teeth and said she had to ask staff to clean her teeth, in order to get them taken care of. The NA reported he cleaned her teeth whenever she asked him to. The resident was observed again with the interim director of nursing (DON) at 11:00 a.m. on 10/07/10. Review of the resident's care plan, dated 06/22/09, found the resident was to be assisted with oral care as needed. - 2. Observation of the resident, on 10/06/10 at 9:00 a.m., 12:00 p.m., and 2:00 p.m. and on 10/07/10 at 10:30 a.m., found the resident in bed. When interviewed on 10/07/10 at 11:00 a.m., Resident #134 reported she would like to get up, but when she did, she often was left up too long (several hours) in the geri chair and it became uncomfortable for her. She said she would be willing to get out of bed for one (1) hour at a time, if staff would put her back to bed in a timely manner. The interim DON was present for this interview. Employee #132 (LPN), when interviewed on 10/07/01 at 10:30 a.m. during an earlier observation of the resident, reported the resident would get up for showers, to get her hair done… | 2014-02-01 | ||
| 11469 | 11469 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-10-07 | 318 | D | UP4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of four (4) sampled residents, who had limited range of motion (ROM) of the left hand, received appropriate treatment and services to prevent further decrease in ROM. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 Review of the resident's medical record did not find any evidence that a brace was supposed to be put on the resident. Observations made on 10/06/10, during the day at 9:00 a.m., 12:00 p.m. and 2:00 p.m., did not find evidence of a brace on the resident's left hand and wrist. On 10/07/10, a brace was found on the resident's left hand at 10:25 a.m., and the nursing assistant (NA - Employee #17) was in the room providing care for the resident, when interviewed, stated he did not care for the resident on a regular basis and did not know about the splint. A licensed practical nurse (LPN - Employee #132) who provided care for the resident, when interviewed at 10:30 a.m. on 10/07/10, said she thought therapy was supposed to get the resident a new brace, but she was not sure if it had been ordered yet. At 11:00 a.m. on 10/07/10, the interim director of nursing (DON) reported the resident was "on the therapy board" but, due to issues with payment, therapy was only doing evaluations for her. Interview with the assessment nurse, on 10/07/10 at 1:30 p.m., found the resident did not have a care plan for a splint, as there was no physician's order for one. Interview the rehab program director (Employee #105), at 1:45 p.m. on 10/07/10, found she did not start here until July 2010 and did not know about any issues regarding this resident. Employee #105 later said the rehab program was going to pick up the resident again and try to do some therapy for her. At 2:10 p.m. on 10/07/10, the occupational therapist (OT - Employee #162) said a new brace with finger separators would be ordered for the resident, and s… | 2014-02-01 | ||
| 11468 | 11468 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 280 | D | SHO311 | . Based on observation, staff interview, and medical record review, the facility failed to revise the nutrition care plan and Kardex used by nursing assistants caring for Resident #50 to accurately reflect the services to be furnished to the resident following a significant change in the resident's status, after she received a fracture to the right arm and became totally dependent on staff for eating. This was true for one (1) of four (4) sampled residents. Resident identifier: #50. Facility census: 118. Findings include: a) Resident #50 Observation of the evening meal, on 10/17/10 at 6:00 p.m., found Resident #50 being fed by a family member. Resident #50's right arm was in a sling, and she was not moving her arm. A second observation of this resident, in the dining room during the noon meal on 10/18/10, found her being fed by a nursing assistant; the resident was totally dependent on staff for eating and drinking. She was not initiating any movement of her right arm to participate in the task of eating. In an interview with the nursing assistant providing care to Resident #50 (Employee #26) on 10/19/10 at 10:00 a.m., Employee #26 was questioned about the amount of assistance Resident #50 required with meals. Employee #26 stated the resident could not move her right arm and she required total assistance with meals. Review of Resident #50's medical record disclosed a significant change in status minimum data set (MDS) was completed on 09/27/10. According to this assessment, the resident was totally dependent on one (1) staff member for eating. Review of her current care plan found the resident's nutrition plan was not reviewed or revised following her change in condition. The interventions listed for maintaining the resident's weight still stated, "Assist resident with meals to extent needed." It was not specific to the amount of staff assistance she needed with eating. This approach was written on 04/27/10, and was reviewed on 07/16/10, but it was not revised after the resident's significant change assessment on… | 2014-02-01 | ||
| 11467 | 11467 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 356 | C | SHO311 | . Based on observation and staff interview, the facility failed to post - accurately and at the beginning of each shift - the required information to identify the staff members providing care and the census of the facility. Observation, on 10/17/10 at 3:40 p.m., found the posted nurse staffing information was dated 10/16/10, and the census information was absent. This practice has the potential to affect all residents and visitors. Facility census: 118 Findings include: a) Observation of the facility's posted nursing staffing data, on 10/17/10 at 3:40 p.m., found the posting was dated 10/16/10. The only nursing staffing data recorded on this posting was for the day shift of 10/16/10, and there was no resident census information recorded as required. An interview with the charge nurse (Employee #49), on 10/17/10 at 3:40 p.m., confirmed this information had not been updated to reflect the numbers of nursing staff or residents currently in the building. | 2014-02-01 | ||
| 11466 | 11466 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 242 | D | SHO311 | . Based on observation, confidential family interview, and staff interview, the facility did not always honor residents' food likes and dislikes. Resident #78 was served beets for dinner, even though this was specifically listed on her tray card as one (1) of the two (2) food items this resident did not like. This was identified during one (1) random meal observation on 10/17/10. Facility census: 118. Findings include: a) Resident #78 During initial tour of the facility on 10/17/10 at 3:40 p.m., interviews were conducted with family members and alert / oriented residents. In one (10 confidential interview, a family member who visited frequently reported the facility staff did not honor residents' food preferences, stating, When you tell them you do not like something, you seem to get it anyway." This family member did report that staff will obtain substitute food items upon request. During an observation on 10/17/10 at 6:00 p.m., a test tray was requested to replace the last tray served on the hall (to check the temperature of food items at the time of service). This tray was intended for Resident #78. The temperature of food items on the tray were within an acceptable temperature range. Observation found the meal served to Resident #78 consisted of Swedish meatballs, pasta, beets, peaches, and milk. Review of Resident #78's tray card, which lay beside the plate on her tray, disclosed two (2) items listed under "dislikes" - beets and green beans. According to assessment information provided by the facility, Resident #78 was not able to participate in an interview due to cognitive impairment. Her food was pureed, and she was fed by staff. She would not have been able to request a substitute for the beets. The dietary manager, who was present at the time of this observation at 6:00 p.m. on 10/17/10, verified that beets were listed as a dislike on this resident's tray card. A new tray was requested for this resident following the testing of her tray. . | 2014-02-01 | ||
| 11465 | 11465 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 241 | D | SHO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview and staff interview, the facility staff failed to treat residents with respect. Staff walked past Resident #71 who was requesting assistance without acknowledging her presence or her request. When interviewed, Resident #71 (who was alert and oriented) reported staff members frequently did not identify themselves to her when giving her care. The resident said she felt like staff treated her like a child. This was observed to be true for one (1) of four (4) sampled residents. Resident identifier: #71. Facility census: 118. Findings include: a) Resident #71 At the initial unannounced entrance to the facility on [DATE] at 3:30 p.m., Resident #71 was observed standing in the doorway of her room waving a water pitcher in the air and saying in a loud voice, "I need some water. Will you get me some water?" As she was making this request, staff members were observed to walk past her and not pay attention to her. A nurse was down the hall passing medications, and two (2) nursing assistants walked past her without saying anything. Resident #71, when interviewed at 4:10 p.m. on 10/17/10, stated she had tried to get the staff to help her several times, but "some of them just run from you." When asked if she knew the names of the staff members that she has difficulty getting help from, she stated, "No, because they do not tell you their name and probably don't want you to know it." She then named several staff members who did treat her respectfully and stated, "They were wonderful and very nice, but some of them just run from you and ignore you." The resident stated, "I do not appreciate being treated like I am a child." This surveyor turned on the call light in Resident #71's room at 4:15 p.m. on 10/17/10. The call light was promptly answered at 4:16 p.m. A nursing assistant (Employee #56) came in the room and asked, "What do you need?" while walking past this resident and looking at the roommate. Resident #71 to… | 2014-02-01 | ||
| 11464 | 11464 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 257 | C | H9I611 | . Based on the results of the complaint investigation (State Complaint Reference # ), it was determined the facility failed to maintain a comfortable building temperature of at least 71 degrees Fahrenheit (F). Facility census: 51. Findings include: a) The National Weather Service (NOAA: www.weather.gov/climate/) temperature archives indicate the outside temperature in the greater Beckley area, beginning on 09/26/10 and continuing through 10/04/10 - a nine (9) day period, was no greater than 69 degrees F. The daily low temperature during this time period was no greater than 58 degrees F. The lowest daily temperature during this time period was 38 degrees F. on 10/02/10. When questioned as to when the facility heating system became functional, the facility's administrator stated an attempt to activate the heating system had failed on 10/01/10 due to a faulty valve. The valve and the heating system became functional on 10/04/10. Without a functional heating system, it would not be possible to maintain the building temperature at a minimum of 71 degrees F during this time period. . | 2014-02-01 | ||
| 11463 | 11463 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 224 | D | H9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to obtain approval from the Social Security Administration before it, while serving as an organizational representative payee, reimbursed Summersville Memorial Hospital for medical debts in arrears for one (1) of twenty-three (23) Stage II residents. Resident identifier: #28. Facility census: 49. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to Summersville Memorial Hospital's skilled nursing unit on [DATE], and expired at the facility on [DATE]. Review of the resident trust fund accounting information revealed the facility paid a total of $733.01 to Summersville Memorial Hospital from Resident #28's personal fund account maintained by the facility on [DATE], [DATE], and [DATE], for services incurred at Summersville Memorial Hospital on [DATE], [DATE], [DATE], [DATE], and [DATE] - all of which were debts made prior to her admission to the skilled nursing unit. During a telephone interview with the resident's former medical power of attorney representative (MPOA) and spouse on [DATE] at approximately 8:00 p.m., they spoke their belief that the facility should have forwarded any extra money the resident had in her personal account to the resident's burial fund rather than paying bills that were five (5), six (6), and seven (7) years old and which incurred when she resided in the acute care portion of the facility. During an interview with the staff member responsible for patient accounts (Employee #130) on [DATE] at 9:30 a.m., she said the skilled nursing unit is a subdivision of Summersville Memorial Hospital, and their tax identification numbers are the same. She handles accounts for the skilled nursing unit and explained that Resident #28's old debts to Summersville Memorial Hospital had been turned over to a collection agency. She said she assumed that, if a resident had a previous bill from any hospital or other bill (s… | 2014-02-01 | ||
| 11462 | 11462 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2010-11-18 | 246 | E | FROJ11 | . Based on resident interview and review of facility records,the facility failed to assure nine (9) of nine (9) sampled residents received prompt assistance when their call bells were activated. Resident identifiers: #95, #78. #58, #67, #6, #25, #49, #44, and #105. Facility census: 104. Findings include: a) Resident #95 In an interview conducted on 11/17/10 at 9:15 a.m., Resident #98 stated that she has great difficulty, at times, getting staff to answer her call light. She stated she has had to wait on occasion from thirty (30) minutes to one (1) hour for assistance. Following the resident interview, a licensed practical nurse (LPN - Employee #99) was noted to be outside the resident's room with a medication cart. When asked how she supervised the unlicensed staff to assure that resident call lights were answered in a timely manner, Employee #99 stated that staff members carry beepers to let them know when a resident's light has gone off. When asked to inspect her beeper, the nurse stated that she had let the nursing assistant (NA) use it. On 11/18/10 at 2:05 p.m., the administrator provided a document which identified how the beeper system operates. Review of the document found that, when a resident activates a call light, the beeper of the NA assigned to the resident goes off. If the call light is not answered after 2.8 minutes, the beepers of NAs on the second wing sound. If the call light is not answered after 8.4 minutes, the nurse's beeper sounds. If the call light is not answered after 11.2 minutes, the beeper of the clinical care supervisor (CCS) sounds. If the call light is not answered within 14 minutes, the beeper of the director of nursing (DON) sounds. The administrator was asked to provide documentation of the wait times for assistance after the call light was activated by Resident #95 for 10/19/10, 10/30/10, and 11/06/10. Review of the information provided found Resident #95's call light was not answered in a timely manner, with the following intervals found between the time the resident activated… | 2014-03-01 | ||
| 11461 | 11461 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2010-11-18 | 240 | G | FROJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her "they had thrown her out and made her go". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), "If there was any way possible, I would like her to go, but she probably won't." He stated his mother had regularly refused… | 2014-03-01 | ||
| 11460 | 11460 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2010-11-18 | 225 | E | FROJ11 | . Based on review of facility documents, family interview, and staff interview, the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were reported and investigated in accordance with State law for three (3) of three (3) allegations reviewed. Resident identifiers: #26, #105, and #44. Facility census: 104. Findings include: a) Resident #26 Review of facility documents found that, on 09/23/10, Resident #44 complained to the social worker (Employee #88) that she had given a check received from her daughter for $150.00 to a staff member to deposit into her resident trust account. The resident further stated the check was never credited to her account. On 09/24/10, Employee #88 reached the following conclusion: "Resident was unable to give specifics of check nor exact time and place when check was allegedly given to (staff). No evidence in place to support existence of check." Further review found this resident's allegation of misappropriation of property had been handled as an in-house complaint and was not reported to State officials, including the State survey and certification agency, as required. Employee #88 was asked if he had called to daughter to determine whether she had provided the resident with a check for $150.00 prior to reaching this conclusion. He stated, on the afternoon of 11/17/10, he had not contacted the resident's daughter. After this prompting, Employee #88 contacted the resident's daughter and determined the daughter had sent the resident a check for $150.00 on 07/05/10, and the check had been deposited to the resident's account on 09/14/10. The facility failed to assure this allegation of misappropriation of resident property was immediately reported and thoroughly investigated as required. -- b) Resident #105 During an interview on 10/27/10 at 3:45 p.m., a family member stated that, while his mother was a resident at the facility, he had visited and found her soaked with urine. He stated he reported this to the administrator. An interview with… | 2014-03-01 | ||
| 11459 | 11459 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 441 | E | 1I0H11 | . Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #58 During the evening meal service on the dementia unit on 05/02/11 at 5:30 p.m., observation found a registered nurse (RN - Employee #58) washed her hands and then turned off the water faucet before obtaining a paper towel. Review of the facility's policy and procedure for hand washing (dated 01/2010) found in Section C at Item 3: "When washing hands with soap and water, wet hands first with water, apply soap and rub hands together vigorously for at least 20 seconds (Centers for Disease Control (CDC), 2010) covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet." The above was reviewed with the administrator at 3:30 p.m. on 05/10/11. b) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Employee #39) distributing a meal tray to Resident #107 in the resident's room; while doing so, Employee #39 touched the resident's overbed table and water pitcher. Without washing hands or using hand sanitizer, Employee #39 then went to the food cart and obtained another tray, which he served to Resident #36. The employee then washed his hands before returning to the food cart to obtain another resident's meal tray for distribution. This finding was reported to the administrator at approximately 1:30 p.m. on 05/05/11. . | 2014-03-01 | ||
| 11458 | 11458 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 425 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, a resident received a daily dose of Lisinopril (an ACE inhibitor used to treat hypertension) for five (5) consecutive days even though his record noted he was allergic to this classification of drugs, and he received one (1) of these doses after the physician discontinued the medication due to the allergy. Resident identifier: #61. Facility census: 129. Findings include: a) Resident #61 Observation during medication pass revealed Resident #61 received a dose of Lisinopril 2.5 mg at approximately 9:00 a.m. on 05/10/11. Record review revealed a physician's telephone order, dated 05/09/11 at 9:00 a.m., with clarification of orders to "D/C (discontinue) Lisinopril - allergic to Ace Inhibitors." Review of the medication administration record (MAR) for May 2011 revealed Resident #61 received Lisinopril 2.5 mg orally daily at 9:00 a.m. on 05/06/11, 05/07/11, 05/08/11, 05/09/11, and 05/10/11. In the "allergies [REDACTED]. Review of the monthly recapitulation of physician's orders [REDACTED]. Also found on the monthly recap was an order for [REDACTED]. These orders were checked by a nurse (Employee #167) as attested by her signature which was dated for 05/05/11. Further review of the physician's telephone orders found an order dated 04/14/11 at 6:00 p.m., stating "allergies [REDACTED]. During an interview with a nurse (Employee #18) on 05/10/11 at approximately 4:30 p.m., she agreed the order to stop the Lisinopril was written on 05/09/11 at 9:00 a.m., but the MAR was initialed to indicate this medication was administered by the nurse at 9:00 a.m. on 05/10/11. Employee #18 agreed the clarification order dated 05/09/11 noted the resident was allergic to ACE Inhibitors, as did both the MAR and the monthly recapitulation of physician's orders [REDACTED]. Subsequent record review found an incident report was completed on 05/10/11 at 5:00 p.m., and the physician was notified that the Lisinopril (w… | 2014-03-01 | ||
| 11457 | 11457 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 371 | F | 1I0H11 | . Part I -- Based on observation, record review, 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 have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 129. Findings include: a) Observations of the dietary department, with the dietary manager (Employee #21) as part of the initial tour on 05/02/11 at 3:00 p.m., found large stainless steel mixing bowls were still wet when being stored and the shelf on which they were stored was wet. Review of the recent county sanitarian report, dated 02/23/11, found the dietary department was cited for not allowing pans to air dry before stacking them. b) Also found during the initial tour were the following: - Plastic containers of whole and skim milk in the walk-in refrigerator were not dated when opened, so dietary staff could determine how long each product had been opened and whether it was still safe for consumption. - Oven doors, when opened, were found to have food debris spilled across the edges and to be in need of cleaning. c) Observation of nourishment station on the North unit, on 05/10/11 at 2:40 p.m., found in the refrigerator a open / half-empty container of honey-thickened liquid that was not dated when opened. This finding was related to the dietary manager at 1:00 p.m. on 05/11/11. -- Part II -- Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Empl… | 2014-03-01 | ||
| 11456 | 11456 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 366 | E | 1I0H11 | . Based on observation and staff interview, the facility failed to ensure staff offered food substitutes to five (5) randomly observed residents when they did not eat their entrees at the evening meal on 05/02/11. Resident identifiers: #55, #114, #13, #65, and #147. Facility census: 129. Findings include: a) Residents #55, #114, #13, #65, and #147 During the evening meal service beginning at 5:30 p.m. on 05/02/11, observation found these five (5) residents left the North dining room between 5:30 p.m. and 5:50 p.m.; none of the five (5) had eaten their entrees. Staff members were in the dining room assisting residents who required spoon feeding and other assistance; however, no one acknowledged these residents leaving, and no one offered any of them a substitute for their uneaten entrees. On 05/10/11 at 1:00 p.m., this was discussed with the administrator (ADM - Employee #200). At that time, the ADM confirmed staff should monitor residents who feed themselves, as well as those who required assistance, to assure all residents are offered substitutions as needed. . | 2014-03-01 | ||
| 11455 | 11455 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 356 | C | 1I0H11 | . Based on observation and staff interview, the facility failed to post nursing staffing information which contained all the elements required by this regulation. In addition, the posted information was not documented in a clear, readable format. This practice had the potential to affect all facility residents, families, and guests. Facility census: 129. Findings include: a) During tour on 05/02/11 at 3:00 p.m., observation of the posted nursing staffing information found it did not differentiate between registered nurses and licensed practical nurses. Additionally, it was not documented in a clear manner that any person reviewing it could understand. The confusion associated with reading the form was confirmed by the staff scheduler (Employee #162) during an interview at 3:45 p.m. on 05/02/11. . | 2014-03-01 | ||
| 11454 | 11454 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 325 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a physician-ordered therapeutic to one (1) of thirty-nine (39) Stage II sample residents in an effort to maintain acceptable parameters of nutritional status such as protein levels. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Her most current care plan, which was last reviewed by the interdisciplinary team on 03/30/11 (with additional handwritten entries added after that date), included the following problem statements related to nutrition (quoted as written): - "111 - therapeutic diet - wt (weight) fluctuates due to [MEDICAL CONDITION] - wt loss desired" (dated 01/12/11) - "Non-compliant /c (with) diet & fluid rest (restriction)" (dated 04/28/11) - "181 - Risk for skin breakdown related to diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]" (dated 01/06/11) - "[MEDICAL CONDITION]" (dated 03/30/11) None of the above problems, nor any of the other problems on the comprehensive care plan, included an intervention to provide the resident with addition protein. -- 3. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, "... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow poin… | 2014-03-01 | ||
| 11453 | 11453 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 323 | E | 1I0H11 | . Based on observation, review of material safety data information, and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as possible. A hazardous cleaning product was left in a resident room, hazardous cleaning products were stored in an unlocked cabinet in the North shower room, and wooden handrailing in the corridors had splintered and/or rough areas, creating a potential for resident injury. These practices had the potential to affect more than an isolated number of residents. Facility census: 129 Findings include: a) On 05/03/11 at 2:18 p.m., a cleaning product in a spray bottle was observed in room 311. The name of the product was "T B QUAT". The bottle contained directives to "keep out of reach of children" and noted the product was a "hazard to humans and domestic animals". Review of the material safety data sheet for the product revealed the following identified hazards: - "Corrosive to eyes. Will cause eye burns, Permanent eye damage or blindness may result without immediate first aid treatment. Harmful or fatal if swallowed." - For ingestion: "May cause nausea, vomiting, and swelling of the larynx, and skeletal muscle paralysis affecting ability to breath, circulatory shock, and convulsions." - "Inhalation of mists may cause irritation to the nose, throat, and mucous membranes. Tissue damage and Pulmonary irritation. Severity depends upon degree of exposure." - For skin contact: "Contact may cause mild to severe irritation, drying, and dermatitis. Health effects depend on degree of exposure." At 2:35 p.m. on 05/03/11, the director of nursing (DON - Employee #49) was asked to point out where the product should be stored. The DON went to the North shower room and pointed out the cabinet in which the products were stored. The cabinet had an unlocked lock on the doors. Upon inquiry, the DON confirmed the cabinet was supposed to be locked. -- b) Observations of the safety of handrails and other environmental issues were conducted in the mid afternoo… | 2014-03-01 | ||
| 11452 | 11452 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 280 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plan for one (1) of thirty-nine (39) Stage II sampled residents to address her low [MEDICATION NAME] level. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, "... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow pointing up) Protein (renal). ..." Subsequent entries, made by the dietary manager on 01/06/11, 01/21/11, 02/21/11, and 03/21/11, also noted the provision of 1-1/2 protein with the resident's diet. On 04/29/11, the dietitian noted, "... Labs reviewed - 4/26 Alb ([MEDICATION NAME]) 2.5 - moderately depleted visceral protein stores - likely r/t (related to) [MEDICAL CONDITION] / diuretic tx (treatment) ..." -- 3. Review of the March 2011 recapitulation of physician orders [REDACTED]." (The word "protein" was handwritten, while the rest of the order was typed.) Review of the May 2011 recapitulation of physician's orders [REDACTED]. -- 4. Interview with the dietary manager (Employee #21), on 05/05/11 at 9:56 a.m., revealed that "1-1/2 protein" meant the resident was to receive 1-1/2 sized portions of each protein serve… | 2014-03-01 | ||
| 11451 | 11451 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 279 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview, the facility failed to develop a care plan for one (1) of thirty-nine (39) Stage II sampled residents who had distinct food preferences. Resident identifier: #90. Facility census: 129. Findings include; a) Resident #90 Record review revealed this resident was admitted to the facility on [DATE]. Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident further stated it was " not necessarily that I don ' t like them, they don ' t like me " . During the survey, it was confirmed the resident was receiving foods which were noted as dislikes on his tray card. Review of the resident's comprehensive care plan, on the morning of 05/05/11, revealed nothing regarding food preferences and/or foods that did not " like him " . This was brought to the attention of the dietary manager (DM - Employee #21) at 10:45 a.m. on 05/05/11. At that time, the DM confirmed there was no care plan for the resident's food preferences. On 05/06/11, the DM provided a care plan, dated 05/06/11, related to preferences for Resident #90. It stated as the problem, "Resident will report he receives food not on his preferences even if they were not served that day." There were no associated goals and interventions to assure the resident's known preferences were honored and/or to assure the resident's food preferences were periodically updated. Additionally, the problem, as stated, was not the problem expressed by the resident. The resident was getting foods he previously told the facility he did not like and that did not " like him " . His newly written care plan did not address this problem at all. On 05/10/11 at 4:55 p.m., an interview regarding this care plan was conducted with the director of nursing (DON - Employee #49). The DON agreed a care plan for the resident to report to staff was not a sufficient m… | 2014-03-01 | ||
| 11450 | 11450 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 253 | E | 1I0H11 | . Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable resident environment. Prompt housekeeping services were not provided to address a strong, persistent, unpleasant odor of urine in the room of Resident #72, one (1) of thirty-nine (39) Stage II sample residents. Routine maintenance services were not provided to ensure the door to the central shower room on the North unit and the wooden handrails in the corridors on the North, East, and Alzheimer's units were free of damage that prevented the surfaces from being able to be effectively cleaned / sanitized. Resident identifier: #72. Facility census: 129. Findings include: a) Resident #72 Observation, on 05/03/11 at 3:09 p.m., revealed the presence of a strong urine odor in the hallway outside Resident #72's room. Numerous staff was observed walking past the room without intervention for the odor as follows: - At 3:10 p.m., an unidentified aide; - At 3:11 p.m., a nurse (Employee #18); - At 3:12 p.m., a nurse aide (Employee #52); - At 3:13 p.m., a nurse (Employee #85); - At 3:14 p.m., an unidentified housekeeping employee; - At 3:15 p.m., Employee #85 and the housekeeping employee; and - At 3:18 p.m., Employee #85. During an interview with the assistant director of nursing (ADON - Employee #112) on 05/03/11 at 3:22 p.m., she acknowledged the presence of the strong urine smell in Resident #72's room and in the hallway outside his door. A restorative aide (Employee #34) emptied Resident #72's urinary drainage bag, but no odor could be detected in the plastic receptacle into which the urine was drained or in the bathroom when the urine was emptied into the commode; she said the odor may have come from the urinary catheter bag having drained "urine onto the floor and the smell seeped into the flooring (laminate)" at some previous point in time, and she agreed the floor on the left side of his bed was a little sticky. The restorative aide checked and did … | 2014-03-01 | ||
| 11449 | 11449 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 252 | E | 1I0H11 | . Based on observation and staff interview, the facility failed to provide a homelike environment during resident dining in the North dining room. Staff walked in and out of the dining room, to an office at the back of the dining room, numerous times during the meals. This was not a homelike environment which de-emphasized the institutional character of the setting. This practice had the potential to affect more than an isolated number of residents who had their meals daily in the North dining room. Facility census: 129. Findings include: a) During observation of resident dining in the North dining room during the evening meal on 05/02/11, several facility staff members were observed continuously coming and going through the dining room into a room at end of the dining room. This gave the appearance that resident dining was not nearly as important as whatever staff members were doing in the room at the end of the dining room. The dining room was an avenue to an office, instead of a homelike area for meals. On 05/04/11, meal service in the North dining room was again observed. Between 12:00 p.m. and 12:20 p.m., a period of twenty (20) minutes, staff members went through the dining room into the room at the back eleven (11) times, and from that room through the dining room nine (9) times. Later on 05/04/11, it was learned the doorway at the end of the dining room led to the office shared by the scheduler and staff development. This doorway also led to a conference room. At 1:00 p.m. on 05/10/11, an interview was conducted with the administrator (Employee #200), who confirmed this was not creating a homelike environment which de-emphasized the institutional character of the setting. . | 2014-03-01 | ||
| 11448 | 11448 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 242 | D | 1I0H11 | . Based on family interview, observation, staff interview, and review of the resident tray cards, the facility failed to ensure two (2) of thirty-nine (39) Stage II sample residents had the right to make choices about aspects of life in the facility that are significant to the residents. Resident #63's family complained that Resident #63 was wearing clothing that was not hers and the resident's closet contained clothing that did not belong to the resident. Resident #90's food preferences were not honored. Facility census: 129. Findings include: a) Resident #63 During an interview on 05/03/11 at 3:49 p.m., Resident #63's family reported finding the resident wearing clothing that did not belong to her and looked "terrible". The family member stated they complained about this to a staff member and were given a form to fill out. The resident was given clothing from other residents, and she wore "things that are not hers". The family member reported finding the resident wearing other residents' clothing even after having complained to the facility about the matter. Observation of the resident's closet, with a licensed practical nurse (LPN - Employee #177) on 05/05/11 at 4:15 p.m., found a 2-piece outfit on a hanger with another resident's name in both pieces of the clothing. Also found folded up in the bottom of the closet were two (2) brassieres that had other residents' names on them. Review of the nursing notes found an entry dated 05/07/11 at 3:00 p.m., stating, "Spoke to ... concerning closet and rummaging of a roommate. Gave consent to apply a safety lock to assist with the rummaging behavior (sic) of other peers." -- b) Resident #90 Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident stated he was particularly "upset" about getting gravy. He said it makes him sick, and he got it "last night". The resident stated he could not understand why he always got gravy, because it was noted as a dislike on his tray sl… | 2014-03-01 | ||
| 11447 | 11447 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 241 | D | 1I0H11 | . Based on observation, the facility failed to ensure privacy during a visit for one (1) of thirty-nine (39) Stage II sample residents. A staff member entered the resident's room without first knocking or asking permission to enter the room. At that time, the resident had a visitor. Resident identifier: #173. Facility census: 129. Findings include: a) Resident #173 On 05/03/11 at 3:10 p.m., a member of the survey team was conducting a Stage I interview with this resident. Without first knocking and/or asking permission to enter the room, Employee #136 (a licensed practical nurse - LPN) came into the room with a rolling blood pressure cart. Employee #136 walked over to the resident and told her she was going to take her blood pressure. While she was taking the resident's blood pressure, Employee #136 looked over at the resident's visitor (a surveyor) and asked the visitor (surveyor) if she was "doing a diary" for the resident. . | 2014-03-01 | ||
| 11446 | 11446 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 226 | E | 1I0H11 | . Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to develop and implement a policy and procedure that ensured statewide criminal background checks were completed on new hires, to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The "Initial Screening of Prospective Applicants" policy stated, "Provider will conduct criminal background checks on all perspective applicants...", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was complet… | 2014-03-01 | ||
| 11445 | 11445 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 225 | E | 1I0H11 | . Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to complete statewide criminal background checks for five (5) of five (5) sampled employees, in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The "Initial Screening of Prospective Applicants" policy stated, "Provider will conduct criminal background checks on all perspective applicants...", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was completed. However, this pri… | 2014-03-01 | ||
| 11444 | 11444 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 159 | D | 1I0H11 | . Based on record review and staff interview, the facility failed to obtain written authorization to manage personal funds for two (2) of three (3) residents reviewed. The facility managed funds for these residents but had no written authorization to do so. Additionally, based on observation of the official posting of the availability of resident funds, residents did not have access to petty cash on an ongoing basis. Resident identifiers: #148 and #90. Facility census: 129. Findings include: a) Resident #148 Review of personal funds, on 05/10/11 at 2:30 p.m., with the business office manager (Employee #147) revealed this resident had $91.16 in the resident trust fund account. Review of authorizations to manage resident funds revealed a signed resident trust authorization. It had an "x" beside an option indicating the resident did not want the facility to manage her personal funds. -- b) Resident #90 Review of personal funds, with Employee #147 on 05/10/11 at 2:30 p.m., revealed this resident had $9.54 in the resident trust fund account. Review of authorizations to manage resident funds revealed this resident signed a resident trust authorization on 02/01/08. It had an "x" beside the option indicating the resident did not want the facility to manage his personal funds. -- c) During the initial tour, on 05/02/11 at 3:00 p.m., a framed notice regarding resident funds was observed outside the business office, stating the times the resident's funds were available at the business office and times the funds were available at the East nursing station. Based on the information on this sign, resident funds were not available from 5:00 a.m. to 8:00 a.m. Monday through Friday, or from 8:00 a.m. to 10:00 a.m. on Saturday and Sunday. During an interview with Employee #147 on 05/10/11 at 2:30 p.m., an inquiry was made regarding when funds were available to the residents. Employee #147 stated the residents had access to their funds twenty-four (24) hours a day, seven (7) days a week. She also stated there was a notice posted to … | 2014-03-01 | ||
| 11443 | 11443 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 156 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to inform rights of their rights by: (a) failing to post the names and current contact information for all pertinent State client advocacy groups, (b) failing to provide accurate appeals information for one (1) of thirty-nine (39) Stage II sample residents, and (c) failing to provide a liability notice to one (1) of thirty-nine (39) Stage II sample residents when Medicare-covered skilled services were discontinued. Resident identifiers: #139 and #2. Facility census: 129. Findings include: a) On 05/11/11 at 11:00 a.m., the surveyor went with the administrator (Employee #200) and the social worker (Employee #129) to find where the required agency postings were located in the facility. It was observed that addresses were not posted at the time. A poster with agency addresses had been in the administrator's office in a framed poster. She said they were taken down so she could change the address of the state agency. The current state agency address will be a year old in July 2011. On 12:46 p.m. on 05/11/11, the administrator presented the surveyors with additional pamphlets, signs, forms, etc. with the advocacy groups names, address and phone numbers listed on it. These were not available at the time of survey. b) Resident #139 Record review revealed that, on 03/17/11, Resident #139 received conflicting notification of transfer / discharge related to which State agency to contact for appeals related to his discharge from the facility to home. Page 2 of the "Notification of Transfer / Discharge" listed several State agencies to which a resident may appeal the transfer / discharge decision, although the only correct State agency was the Office of Inspector General's Board of Review. During an interview on the early afternoon of 05/03/11, after request was made for a copy of the information provided to residents upon transfer or discharge, the administrator reported the 2… | 2014-03-01 | ||
| 11442 | 11442 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2010-11-04 | 353 | F | UZ0K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility-generated Form CMS-672 (Resident Census and Conditions of Residents) and facility-generated Form CMS-802 (Roster / Sample Matrix), review of the nursing staffing calculation worksheet completed by the facility for the time period of 10/10/10 through 10/23/10, review of payroll records, nursing staff postings, and assignment sheets, review of resident council meeting minutes for 10/18/10, random observations, family interview, and staff interview, the facility failed to provide sufficient direct care nursing staff on the 7:00 a.m. to 3:00 p.m. (7-3) shift to meet the assessed care needs of dependent residents and to also answer call lights in a timely manner. This practice has the potential to affect all residents in this facility. Facility census: 94. Findings include: a) According to the CMS-802 (Roster / Sample Matrix) generated by the facility from data collected through the minimum data set (MDS) assessments, there were ninety-four (94) residents living there at the time of this investigation. b) According to the CMS-672 generated by the facility from data collected through the MDS assessments: For bathing - zero (0) residents were independent, seventy-five (75) residents required the assistance of one (1) or two (2) staff, and nineteen (19) residents were totally dependent. For dressing - four (4) were independent, sixty-eight (68) residents required the assistance of one (1) or two (2) staff, and twenty-two (22) residents were totally dependent. For transferring - five (5) were independent, seventy-four (74) residents required the assistance of one (1) or two (2) staff, and fifteen (15) residents were totally dependent. For toilet use - four (4) were independent, sixty-seven (67) residents required the assistance of one (1) or two (2) staff, and twenty-three (23) residents were totally dependent. For eating - twelve (12) were independent, eighty (80) residents required the assistance of one (1) or two (… | 2014-03-01 | ||
| 11441 | 11441 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2011-01-25 | 309 | G | 65CW12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records (both electronic and paper), staff interviews, review of in-service records, review of disciplinary action documents, review of controlled substances records, review of the facility's documentation regarding falls, review of the facility's investigations of falls and reportable events, and observations, the facility had failed to ensure a resident received appropriate and timely interventions for management of the onset of pain. The lack of pain management constituted actual harm to the resident. Review of documentation found a resident had sustained falls in December 2010. The last fall was noted to have occurred on 12/25/10. She later began to demonstrate both verbal and non-verbal indicators of pain. During this time, she also began to exhibit a limp and a decreased effort to ambulate. The onset of pain symptoms was evident beginning on the late morning of 12/31/10. A total of six (6) doses of Tylenol 650 mg were documented as given. The effectiveness of those doses was not documented (or documented in the negative), and documentation indicated the resident's pain symptoms persisted. The physician saw the resident in the afternoon on 12/31/10. He noted the resident was crying but did not order any additional pain medication. There was no evidence further treatment of [REDACTED]. On 01/02/11 at 23:39 (11:39 p.m.), the resident was sent to the hospital where it was found she had a [MEDICAL CONDITION]. Through review of medical records, review of the controlled substances sign-out book for Mary's Garden, staff interviews, observations, and review of documentation of in-services and disciplinary actions, it was determined the facility had identified and addressed the deficits in the provision of care related to pain management for Resident #50. This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/25/09) and before the start of… | 2014-03-01 | ||
| 11440 | 11440 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2010-11-18 | 323 | G | 65CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision and/or assistive devices for one (1) of five (5) residents reviewed to prevent avoidable accidents. Resident #89, who had experienced a decline in physical condition and was diagnosed with [REDACTED]. There was no evidence the facility evaluated the resident's ability to be unsupervised in the wheelchair due to her condition at 9:00 a.m., her weakened condition due to pneumonia, and her potential weakness as the result of refusing both meals prior to the fall. The resident was not assessed to determine whether supervision to avoid an accident was necessary. The facility had not evaluated the risk of this resident having an avoidable accident or implemented any interventions to reduce the risk of a fall. Later that day, the resident was gotten out of bed and placed in a wheelchair so an air mattress could be placed on the bed. She was unsupervised in the wheelchair and was found on the floor at 4:23 p.m. on 10/13/10. She sustained injuries and required hospitalization . There was no evidence that staff, who placed her in the wheelchair, had been made aware the resident was put to bed earlier in the day because she was leaning forward in her wheelchair. Subsequently, the resident experienced a fall from the wheelchair with injuries. Resident identifier: #89. Facility census: 88. Findings include: a) Resident #89 When reviewed on 11/17/10 and 11/18/10, the medical record of Resident #89 disclosed this [AGE] year old female had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - On 10/13/10 at 9:00 a.m., a nursing note stated, "Resident up in w/c (wheelchair) with 1 person assist leaning (sic) forward in w/c assisted resident back to bed." A nursing note, dated 10/13/10 at 9:31 a.m., stated, "Resident's daughter was upset over finding her mother slumped in her bed ...Resident has shown a steady decline over last several months. Oral… | 2014-03-01 |
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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 );