CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11332 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 152 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. . | 2014-04-01 | ||
| 11333 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 225 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to report allegations involving mistreatment and/or neglect to the appropriate agencies in accordance with State law for three (3) of six (6) sampled residents. Resident identifiers: #37, #38, and #67. Facility census: 89. Findings include: a) Resident #37 A review of the medical record revealed Resident #37 was an [AGE] year old male who has been determined to lack the capacity to form healthcare decisions, and his minimum data set and care plan indicated he was totally dependent upon staff for hygiene. A review of a grievance form revealed that, on 11/16/10, the resident's wife / healthcare surrogate (HCS) reported to a nurse (Employee #7) that the resident's nails were dirty at times and that she always had to cut his nails herself. The nurses' notes indicated this allegation of neglect was investigated and being followed up by Employee #7 and a nursing assistant and, when checked on 11/17/10, his nails were clean. Daily monitoring of the resident's nails was ordered by the physician and added to the care plan. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- b) Resident #38 A review of the clinical record for Resident #38 revealed an [AGE] year old male with [DIAGNOSES REDACTED]. He had been determined by the attending physician to lack the capacity to form healthcare decisions, and his niece was his medical power of attorney representative (MPOA). A grievance form was filed on 11/08/10, after the facility received a letter from the MPOA stating she had spoken to a staff member two (2) weeks prior and complained that the resident had become unable to physically lift his arm enough to feed himself, but nothing had been done and he was still having his tray set up and being left to feed himself. During an interview with the MPOA at 12:50 p.m. on 12/28/10, she verified she had told three (3) different employees about the fact that the resident could no longer feed himself or get a drink of water on his own. The MPOA stated the resident's mouth was very dry and the nurse had told her that he was losing weight. Her only answer from nursing was, "We'll write it in the notes." She stated she had asked an aide to feed him but was told they needed to get an "okay" from the nurse. She stated that, after she wrote the letter, the facility took action, had tests done, and instructed the staff to feed him. The original assessment by the registered dietitian (RD), on 06/20/10, noted his weight as 204.2 pounds and his intake at 92%. A dietary entry on 12/16/10 noted, "MPOA aware of Monthly weight trigger; Resident has had a 9.54% wt. loss x 1 month, 10.15% wt. loss x 3 months and 14.68% wt. loss x 6 months." An investigation took place as evidenced by an immediate speech therapy evaluation; a referral to the Veteran's Hospital for an evaluation of his decline; and, on 11/10/10, he was changed to having meals in the restorative dining room. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- c) Resident #67 A review of the grievance reports revealed that, on 11/15/10, Resident #67 (who had been determined by the attending physician to have the capacity to form her own healthcare decisions on 10/10/10) reported allegations that she was not getting the care she needed. She stated to Employee #8 (the admissions person) that: (1) she could not reach her call bell; (2) she hadn't been gotten out of bed for two (2) days, and (3) one (1) of the aides (Employee #9) had been rude to her when she asked to get up and told her she would have to wait and that he didn't have to do what she said. Employee #8 recorded the allegations and began an investigation, and counseling was done with the staff, but these allegations of neglect were not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. During the investigation, Employee #10 gave a signed statement the resident had also reported to her on 11/12/10, that her light was not being answered. -- d) During an interview with the administrator, the acting director of nursing, and the social worker at 1:45 p.m. on 12/28/10, this surveyor stated to them that the above grievances contained allegations of mistreatment and/or neglect and, as such, should have been immediately reported to the appropriate State officials prior to the initiating of investigations. The outcome of the investigations should also have been reported. The three (3) of them reviewed the grievances and did not offer any alternative explanations but stated that they would file reports as soon as possible. . | 2014-04-01 | ||
| 11334 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 323 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to ensure one (1) of six (6) sampled residents was free from accident hazards over which the facility had control, and the facility failed to provide adequate supervision and/or assistive devices by failing to put preventive interventions into place after an identified accident. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of the medical record revealed Resident #23 was a [AGE] year old female, who was alert and oriented, but whose sister who had been appointed to serve as her health care surrogate (HCS) per the social worker, to assist her with healthcare decisions. A facility investigation report indicated that, on 12/15/10, the resident was found with her right foot caught in the siderail of her bed in her bedroom resulting in redness of the entrapped area. The resident had a physician's orders [REDACTED]. A Side Rail Evaluation Screen was completed on 12/27/10, and the decision was made to add padded coverings to the siderails. The assessment nurse (Employee #6) presented a copy of the care plan at 2:00 p.m. on 12/28/10, with an added intervention (hand-written) dated 11/22/10 which read: "Bilateral 1/2 SR padded for T & R (turning and repositioning)." An observation of the resident was made at 10:45 a.m. on 12/27/10, while she was lying in bed in her room. Both 1/2 siderails were raised and appeared to have a satisfactory fit to the bed, but there was no padding on the rails. In an interview with the resident at that time, she stated she did like having the rails to use when she moved about in bed. She remembered getting her foot caught in the rail and said she was being careful not to do it again. During a staff interview with the interim director of nurses at 11:15 a.m. on 12/28/10, she acknowledged the padding had not been added until the evening of 12/27/10, when she realized that her instructions to the nursing staff to pad the rails "on Friday" had not been carried out. . | 2014-04-01 | ||
| 11335 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 514 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by continuing to indicate, in the physician's progress notes, that two (2) of six (6) sampled residents were on medications and/or dosages that had been changed and/or discontinued. Resident identifiers:#37 and #87. Facility census: 89. Findings include: a) Resident #37 A review of the medical record found Resident #37 presently had physician's orders [REDACTED].@ bedtime" (with a start date of 09/13/10) and "[MEDICATION NAME] (insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - once daily Everyday: 4 units" (with a start date of 07/07/10). A review of the physician's progress notes revealed the physician's assistant (Employee #4) had documented on all entries back to 06/15/10 that the resident was receiving the following drug therapy for treatment of [REDACTED]. DM II (diabetes mellitus type II): [MEDICATION NAME] 20U qhs (each night). Presently taking [MEDICATION NAME] 2U with supper and continue 4U with breakfast and lunch. Will continue to monitor qid (four-times-a-day)." During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented "the nurses know not to go by (his) notes." The medical director, who was present at exit, stated that corrections would be made. -- b) Resident #87 A review of the physician's progress notes written by the physician's assistant (Employee #4), on 12/09/10, 10/19/10, 09/21/10, and 08/24/10, all stated Resident #87 was being treated with the following: "1. [MEDICAL CONDITION]'s chorea: Klonopin 1 mg bid (twice daily). [MEDICATION NAME] mg qhs for [MEDICAL CONDITION]. [MEDICATION NAME] 7.5 mg 1 po (by mouth) qhs." A review of the record found the [MEDICATION NAME] was discontinued on 07/22/10 and [MEDICATION NAME] discontinued in August 2009. During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented "the nurses know not to go by (his) notes." The medical director, who was present at exit, stated that corrections would be made. | 2014-04-01 | ||
| 11336 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-01-11 | 318 | E | CVPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase strength and/or range of motion (ROM). Thirty-six (36) residents had physician orders [REDACTED]. Resident identifiers: #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Facility census: 76. Findings include: a) Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77 On 01/10/11, a review of the facility's "Restorative Nursing and Progress Summary" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, twenty-four (24) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on five (5) of ten (10) days. These were Residents #2, #5, #7, #8, #10, #12, #15, #24, #25, #33, #35, #42, #43, #44, #50, #57, #60, #61, #63, #64, #67, #68, #73, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on anywhere between three (3) and eight (8) days of this month. These were Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Each resident had one (1) or more physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She stated, "I am a van driver." An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's "Restorative Nursing and Progress Summary" marked with an "X" indicated that the restorative services was not provided for the resident. She reported the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor. | 2014-04-01 | ||
| 11337 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-01-11 | 311 | E | CVPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase self-performance of transfer / ambulation and/or eating activities. Twenty-four (24) residents had physician orders [REDACTED]. Resident identifiers: #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Facility census: 76. Findings include: a) Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77 On 01/10/11, a review of the facility's "Restorative Nursing and Progress Summary" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, fourteen (14) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on five (5) of ten (10) days. These were Residents #2, #5, #7, #12, #15, #24, #33, #41, #52, #57, #61, #68, #74, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on anywhere between three (3) and eight (8) days of this month. These were Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Each resident had a physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She further stated, "I am a van driver." An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's "Restorative Nursing and Progress Summary" marked with an "X" indicated that the restorative services was not provided for the resident. She further stated that the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor. . | 2014-04-01 | ||
| 11338 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-12-09 | 225 | D | 9K0R11 | . Based on review of abuse / neglect policies, review of employees' personnel files, and staff interview, the facility failed make reasonable efforts to uncover information about any past criminal prosecutions to assure that individuals are not employed who have been potentially found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of seven (7) employee personnel records reviewed. Facility census: 115. Findings include: a) The facility was entered at 12:15 p.m. on 12/09/10, to conduct an unannounced complaint investigation alleging that the facility did not perform necessary screening for potential employees to rule out criminal convictions that would make them unfit for service in a nursing facility. Review of the facility's policy addressing the prevention of resident abuse / neglect "1.0-WV Abuse Prohibition" (revised 11/01/09) found the following under the section entitled "Process": "2. The Center will screen potential employees for a history of abuse, neglect, or mistreating residents... "2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service...". Review of the personnel file for nursing assistant (NA) #1 found she had previously worked in the Commonwealth of Virginia. The personnel file contained no evidence to reflect the facility made a reasonable effort to determine whether this individual had criminal convictions in Virginia which would render him / her unfit to work in a long term care facility. An interview with the administrator, on 12/09/10 at 3:10 p.m., confirmed the facility had no evidence that NA #1 had been screened for criminal convictions in Virginia. | 2014-04-01 | ||
| 11339 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 157 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. Record review of nursing notes, from [DATE] until her death on [DATE], found no evidence of communication to the family related to Resident #111 participating in the fine dining or walk-to-dine program. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. . | 2014-04-01 | ||
| 11340 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 280 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. There was also no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 4. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 5. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. . | 2014-04-01 | ||
| 11341 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 323 | G | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON agreed that Resident #111 was not using a tab alarm, self-releasing seat belt, or wheelchair at the time of the fall in the dining room on [DATE]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. -- 8. During an interview with a member of the activities staff (Employee #35) on [DATE] at 3:20 p.m., she said she was the only staff member in the dining room on [DATE] at the time Resident #111 fell , although she was not assigned to be in the dining room that day at any certain time. She said she went to the kitchen on her own initiative on [DATE], to check if any of the trays were ready or if the dietary staff needed her to start pouring drinks. When asked, she said the noon meal was typically served at 12:10 p.m. in the dining room. She stated that, at 11:45 a.m. on [DATE], she looked up and saw Resident #111 walking and hurried to her, but she could not reach the resident before she fell . She said the resident had no alarm or safety belt in place and she was sitting at the table by herself. -- 9. When asked, during an interview on [DATE] at 4:00 p.m., why Resident #111 was in the dining room so early before the meal, the DON said Resident #111 was one of the easiest residents to walk, so she would have been one of the first brought down to the dining room. She said there was no written safety policy or procedure regarding the use of alarms or seat belts that she could find related to fine dining. Resident #111 had an order for [REDACTED]. . | 2014-04-01 | ||
| 11342 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 155 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading "Physical Exam", "... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..." Under the heading "Plan", the CNP recorded, "A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively." - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading "Chief Complaint", "FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied." Under the heading "ROS" (review of systems) was recorded, "I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..." Under the heading "Physical Exam" was recorded, "... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..." Under the heading "Services Performed", the CNP recorded, "Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)." -- 3. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, "... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)." Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, "Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..." - At 6:30 p.m., Employee #8 (another LPN) wrote, "VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting." Employee #6 also wrote the following late entry for 12/03/10, "7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure." - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level "8" on a scale of "1 to 10" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 4. The ER record dated 12/03/10 stated, "... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)." At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- 5. A physician's progress note, dated 12/05/10, stated, "Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done." After the physician was notified of the I&D at approximately 6:30 p.m. on 12/03/10, all further treatment was done by him. -- 6. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. . | 2014-04-01 | ||
| 11343 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 157 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure, for one (1) of seven (7) sampled residents, the physician was notified of an acute change of condition (the presence of a large hematoma), and failed to consult the physician and notify an interested family member prior to a significant alteration in treatment. Resident #118 (who had multiple comorbidities and was on anticoagulation therapy) developed a large hematoma on her left lower extremity, and the facility failed to notify the attending physician of the hematoma. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage) on the hematoma without consulting with the attending physician and without informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. The physician and the MPOA were contacted after the procedure resulted in significant bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on 12/02/10, Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading "Physical Exam", "... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..." Under the heading "Plan", the CNP recorded, "A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively." - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading "Chief Complaint", "FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied." Under the heading "ROS" (review of systems) was recorded, "I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..." Under the heading "Physical Exam" was recorded, "... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..." Under the heading "Services Performed", the CNP recorded, "Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)." There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, "... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)." Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, "Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..." - At 6:30 p.m., Employee #8 (another LPN) wrote, "VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting." Employee #6 also wrote the following late entry for 12/03/10, "7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure." - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level "8" on a scale of "1 to 10" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 6. The ER record dated 12/03/10 stated, "... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)." At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- A physician's progress note, dated 12/05/10, stated, "Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done." -- 8. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. The termination of the services of the CNP was confirmed by the administrator during the exit conference. . | 2014-04-01 | ||
| 11344 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 224 | G | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. The resident's cardiovascular disease was being treated with long-term [MEDICATION NAME] therapy, which included regular monitoring of her [MEDICATION NAME] time (PT) and INR. PT evaluates the ability of blood to clot properly; INR (International normalized ratio) is a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Hemostasis for reporting the results of blood coagulation (clotting) tests. The lab's normal ranges for these tests were PT - 9.2 to 11.8 and INR - 2.0 to 3.0. Record review revealed the following lab results and adjustments made to her [MEDICATION NAME] order in November and [DATE]: Date - [MEDICATION NAME] Dosage - PT / INR - New Order [DATE] - 2.5 mg daily - 42.1 / 4.3 - hold x 2 days [DATE] - ([MEDICATION NAME] held) - 39.8 / 4.1 - [MEDICATION NAME] 2.0 mg daily [DATE] - 2.0 mg daily - 34.5 / 3.4 - [MEDICATION NAME] 1.5 mg daily [DATE] - 1.5 mg daily - 25.8 / 2.4 - same [DATE] - 1.5 mg daily - 27.3 / 2.5 - same [DATE] (at 12:00 p.m.) - 1.5 mg daily - 23.0 / 2.0 - same [DATE] (at 8:10 p.m.) - 1.5 mg daily - 23.3 / 2.3 - same On [DATE], the physician gave orders to discontinue the [MEDICATION NAME] and obtain a repeat PT/INR. -- 3. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 4. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading "Physical Exam", "... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..." Under the heading "Plan", the CNP recorded, "A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively." - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading "Chief Complaint", "FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied." Under the heading "ROS" (review of systems) was recorded, "I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..." Under the heading "Physical Exam" was recorded, "... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..." Under the heading "Services Performed", the CNP recorded, "Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)." - There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 5. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, "... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)." Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, "Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..." - At 6:30 p.m., Employee #8 (another LPN) wrote, "VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting." Employee #6 also wrote the following late entry for [DATE], "7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure." - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level "8" on a scale of "1 to 10" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 6. The ER record dated [DATE] stated, "... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)." At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 7. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, "Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings." At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that "... area to left leg slightly red warm and hard around wound", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, "Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done." After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was "Acute [MEDICAL CONDITION]". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) "is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..." (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an "unusual occurrence". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation. The termination of the services of the CNP was confirmed by the administrator during the exit conference. . | 2014-04-01 | ||
| 11345 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 225 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to immediately report to State agencies and/or thoroughly investigate an incident involving the neglect of one (1) of seven (7) sampled residents. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. This event was reported to the State survey and certification agency as an "unusual occurrence" without evidence of a thorough investigation. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading "Physical Exam", "... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..." Under the heading "Plan", the CNP recorded, "A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively." - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading "Chief Complaint", "FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied." Under the heading "ROS" (review of systems) was recorded, "I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..." Under the heading "Physical Exam" was recorded, "... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..." Under the heading "Services Performed", the CNP recorded, "Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)." -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, "... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)." Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, "Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..." - At 6:30 p.m., Employee #8 (another LPN) wrote, "VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting." Employee #6 also wrote the following late entry for [DATE], "7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure." - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level "8" on a scale of "1 to 10" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 5. The ER record dated [DATE] stated, "... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)." At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 6. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, "Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings." At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that "... area to left leg slightly red warm and hard around wound", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, "Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done." After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was "Acute [MEDICAL CONDITION]". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) "is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..." (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an "unusual occurrence". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation. | 2014-04-01 | ||
| 11346 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 157 | D | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide prompt notification, to the responsible party of one (1) of forty-two (42) Stage II sample residents, after the resident experienced a change in condition. Resident #120 became agitated while in the dining room on 11/12/10, and the nurse aides had to carry the resident back to her room due to her increased agitation, resistance of care, and physically aggressive behaviors. The resident's medical power of attorney representative (MPOA) did not learn of these events until 11/16/10. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 On the night of 11/12/10, Resident #120 exhibited agitated behaviors that were atypical for her. According to documentation recorded by a licensed practical nurse (LPN - Employee #114), the resident was in the dining room by herself when she became agitated and started carrying around a wet floor sign, hitting the window of the dining room with the wet floor sign. The resident was soiled also due to incontinence. When nurse aides approached her and tried to get her to her room (in order to provide incontinence care), she became more agitated, hitting and kicking the nurse aides. Nurse aides eventually had to carry the resident from the dining room to her room, in order to change her out of her soiled clothes. On 01/06/11 at approximately 2:00 p.m., the social worker (Employee #134) provided a copy of documentation she had collected on 11/16/10. The documentation stated, "(Name), daughter and MPOA for (Resident #120), came into the office about 1:25 PM this date and stated that (name of Employee #73), CNA (certified nursing assistant), told her there was a rumor that 3 CNA's (sic) on south side turned in 3 CNAs from north side for abuse of (Resident #120). The story is that Friday, 11/12/10, night (Resident #120) was hitting and combative with staff. In an attempt to get her calmed they restrained her and in the process bruised her pretty bad. (Daughter's name) indicated that she (the resident) has bruising on her left wrist, right wrist, and a dark blue spot further up her right arm. (Employee #73) told (daughter's name) names (sic) of two CNAs, (names of Employees #65 and #54) both of whom work 3-11 shift. (Daughter's name) was also told that one of the CNAs was new. She inquired about the process when something like this happens. It was explained generally about investigating and reporting. She was rather upset understanding (sic) however, her mother's behaviors at times (sic) but was concerned about the bruises. She was assured we would keep her informed. ..." The resident's daughter became aware of the above incident on 11/16/10, when she came to the facility and Employee #73 approached her with the above information. According to the administrator, the information given to the daughter by Employee #73 did not portray what actually occurred. According to the administrator, Employee #73 did not work on the night of 11/12/10 and had no direct knowledge of what happened, and Employee #73 received a disciplinary action for her actions. On 01/06/11 at approximately 4:00 p.m., the director of nursing (DON) confirmed the facility did not contact the resident's daughter to inform her of what had occurred on 11/12/10. She stated Employee #114 used her nursing judgement on 11/12/10 and elected to not contact the resident's MPOA to inform her of her mother's behavior and of the actions taken to get the resident back to her room and in a more calm state. The DON and the administrator both confirmed the events on 11/12/10 were not typical for the resident. They attributed the increase in aggression to the resident's [DIAGNOSES REDACTED]. . | 2014-04-01 | ||
| 11347 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 309 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, staff interview, and resident interview, the facility failed to provide necessary care and services for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was receiving blood thinners and was observed with excessive bruising to bilateral upper extremities. There was no documentation that the use of blood thinners was being monitored for this resident. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of recent laboratory results, dated 09/09/10 and 11/08/10, found no laboratory results used for monitoring the effectiveness of the blood thinner to regulate clotting. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 4:00 p.m., Resident #15 reported, "I can barely just touch or scratch myself and I bruise. I am on blood thinners, and I think it needs to be checked. I was going to talk to my doctor about it, but I haven't seen him." In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. Interview with the licensed practical nurse (LPN) assigned to Resident #15 (Employee #159), on 12/22/10 at 5:20 p.m., revealed he was not aware of any bruising to Resident #15's bilateral upper extremities. . | 2014-04-01 | ||
| 11348 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 514 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed to maintain a complete clinical record for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was observed with excessive bruising to bilateral upper extremities, and there was no documentation that two (2) of three (3) weekly body audits had been completed in the month of December 2010. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. (See also citation at F309.) | 2014-04-01 | ||
| 11349 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 323 | G | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and chronic obstructive pulmonary disease. The assessor did not identify, as active diagnoses, either osteoporosis or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): "ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia." Goals associated with this problem statement were: "Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning." Interventions to meet these goals included: "Tranfer (sic) with 2 person / Mechanical Lift (sic)." (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - "Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') edema, (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station." The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it "error", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - "C/O (complaint of) pain in left leg. PRN (as needed) analgesic x 1 per order /c (with) No (sic) relief." - 09/03/10 at 2:30 a.m. - "Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..." - 09/03/10 at 3:15 a.m. - "Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)." - After the resident's transfer to the hospital on [DATE], Employee #134 recorded the following series of late entries: - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 7:30 p.m. Resident complaint (sic) of pain to left leg. Assessment completed to left leg. (Symbol for 'no') bruising noted. (Symbol for 'no') redness. (Symbol for 'no') edema, or scratches noted to left leg. resident (sic) c/o pain in the knee area. Resident stated 'I can't feel my legs.' Call placed to MD. resident (sic) medicated for pain per order. Will continue to monitor." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:00 p.m. MD return (sic) call obtain (sic) order for stat xray (sic). POA (power of attorney) aware. (Name of mobile imaging company) aware." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:45 p.m. Xray's (sic) obtained, daughter /c resident at bedside. (Symbol for 'no') complaints of pain at this time. Will continue to monitor resident and await the report." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 10:20 p.m. Resident resting in bed. (Symbol for 'no') discomfort noted. (Symbol for 'no') complaints of pain noted. Awaiting xray (sic) to be faxed to nurses (sic) station. (Symbol for 'no') edema, (symbol for 'no') bruising, (symbol for 'no') redness noted to left leg. Will continue to monitor." This was the last entry in the resident's nursing notes; she did not return to this facility after being transferred to the hospital on [DATE]. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a "date of exam" of "2010-09-02" (09/02/10) contained the following impression: "Left tibia-fibula - Mildly displaced acute fracture of the proximal fibular shaft and fibular head demonstrated." There was no evidence to reflect this acute displaced fracture of the left fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of osteoporosis or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: "Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..." The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be "Unknown". - Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) transferred the resident on 09/02/10 without using a mechanical lift as identified in the resident's comprehensive assessment and care plan. - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: "During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: "'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' "'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. "We didn't use a gait belt; we didn't use a mechanical lift. "'I did not check the Patient information worksheet.' "'I know we are a no lift company.' "'I have used the lift in the past.' ..." -- 5. Upon request, the facility provided a copy of the policy titled "Mechanical Lift" (dated 03/10/10). According to this document, the purpose of the policy is "(t)o move immobile or obese patients for whom manual transfer poses potential for staff or patient injury". Review of the facility's employee handbook revealed, under the heading "Safety Rules" on page 38: "1. Report all accidents immediately, no matter how minor, to your supervisor. Your supervisor is required to make a thorough investigation and to complete an Accident Investigation Report. You are required to complete an Employee Incident Report for on-the-job accidents. "2. Utilize appropriate lifting techniques and body mechanics for all lifting, including patient / resident transfers. All lifting must be performed in accordance with location procedures. Utilize mechanical lifting equipment where appropriate. ..." -- 6. On the Patient Information Worksheet, Resident #147 was listed as requiring "2 person / Mechanical Lift". -- 7. In an interview on 12/22/10 at approximately 3:00 p.m., Employee #134 stated she did work on 09/02/10. She came back to work on 09/09/10 and recorded additional documentation in Resident #147's medical record, after she realized she had made an error regarding the time of the incident in her original note. Employee #134 stated a nurse aide did inform her that the resident complained of pain on the evening of 09/02/10. She assessed the resident's leg, and the resident did not appear to have any swelling, redness or tenderness to her leg during the assessment. She assisted the mobile imaging company during their x-ray of the resident's leg, and the resident did not appear to be in any pain at that time. -- 8. In an interview on 12/22/10 at approximately 3:30 p.m., Employee #141 stated his employment was terminated after this incident, but he was later asked to return to work. He reported he was not the aide assigned to Resident #146 on 09/02/10, but he did assist his co-worker (Employee #152) on that day. He verified they did not use a mechanical lift to transfer the resident from her wheelchair to her bed. He agreed he should have looked to see what type of assistance the resident needed for transferring before he assisted Employee #152, but he reiterated that he had his own assignments and had just agreed to help out a co-worker with a transfer on 09/02/10. -- 9. The assistant director of nursing (ADON - Employee #139) confirmed, during an interview on the afternoon of 12/22/10, the facility was a "no lift company". The ADON also confirmed that no incident / accident report was completed related to the events that took place on the evening of 09/02/10 involving Resident #147. -- 10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. . | 2014-04-01 | ||
| 11350 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2010-12-16 | 225 | D | 17LC11 | . Based on record review, staff interview, and confidential staff interview, the facility failed to report an allegation of resident neglect by a nursing assistant to the appropriate State officials agencies when the identity of the alleged perpetrator was known. This was evident for one (1) of five (5) sampled residents. Resident identifier: #32. Facility census: 65. Findings include: a) Resident #32 Record review revealed Resident #32 received a head injury of unknown origin. Subsequently, this resident was transported to the emergency room for evaluation, then returned to the facility the same day. Record review revealed the facility reported this injury of unknown source to the appropriate State agencies, because the source of the injury was not observed by any person, it could not be explained by the resident (who was cognitively impaired due to a disease process), and the injury was suspicious because of the location and extent of the injury. Further record review revealed a licensed practical nurse (LPN - Employee #32) completed an incident report on the date and time of the discovery of the injury and documented an allegation that a nursing assistant caused the injury during turning and failed to notify the nurse of what she had done. -- Interview with the administrator, director of nursing, and the licensed social worker, on 12/14/10 at 3:00 p.m., revealed their belief that it would have been physically impossible for Resident #32's head to hit the bedside stand while being turned; they reported the aides "speculated" about what might have happened, and a former employee (Employee #84, a nursing assistant who was terminated last week) and other staff who were working the evening of the incident, when interviewed, admitted having no knowledge of how the injury happened. Subsequently, the administrator felt the allegation was hearsay, and the facility did not substantiate abuse or neglect in their investigation of the incident. -- Interview with Employee #32, on 12/14/10 at 3:25 p.m., revealed that the identity of Employee #84, who allegedly caused a head injury to Resident #32, was told to her and she included this allegation on the incident report but without writing the names of the alleged perpetrator or the reporter of this information. -- In an interview, another LPN (Employee #58) confirmed that she, too, was told of the allegation at the same time as Employee #32, that Employee #84 had allegedly caused the head injury while turning the resident but did not tell the nurse what she did. -- A confidential interview with member of the facility's nursing staff, on 12/15/10 at 12:25 p.m., revealed she heard Employee #84 admit to having injured Resident #32 while turning the resident alone, striking the resident's head against the overbed table, but was afraid to tell the nurse. -- During an interview with the administrator on 12/14/10 at 5:00 p.m., she acknowledged the allegation made against Employee #84 should have been reported to the Nurse Aide Abuse Registry, even though the facility did not substantiate abuse or neglect in their internal investigation. . | 2014-04-01 | ||
| 11351 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2010-12-16 | 281 | D | 17LC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders to perform monthly laboratory testing for one (1) of five (5) sampled residents. One (1) resident in the sample did not receive a monthly complete blood count (CBC) per physician's orders, as evidenced by one (1) CBC lab test omission in March 2010. A CBC drawn a month after the omitted lab test, in April 2010, revealed abnormal findings resulting in the resident's hospitalization Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Record review revealed Resident #67 was diagnosed with [REDACTED]. A hospice encounter occurred in September 2009 but was declined by the family. Review of a facility's Encounter Sheet, dated 12/10/09, revealed the physician was to be consulted regarding increasing the [MEDICATION NAME] dosage, as this resident with multiple contractures and "pain expressed (symbol for with) even slightest movement". -- Record review revealed Resident #67's physician orders included orders for a basic metabolic profile (BMP) every three (3) months and CBC every month. Review of physicians orders effective from 03/01/10 through 03/31/10 revealed both the BMP and the CBC were both due on 03/10/10 and all CBCs were to be sent to Hospital #1. The BMP, requested and completed on 03/19/10 by the contracted lab service at Hospital #2, yielded results similar to the previous quarterly BMPs; however, there was no evidence to reflect the monthly CBC was requested and/or completed in March 2010. A CBC, requested and completed by the contracted lab service at Hospital #2 on 04/23/10, contained the following abnormal laboratory results: - WBC (white blood cell count) 1.2 (normal reference range 4.9 - 10.8); - RBC (red blood cell count) 1.98 (normal reference range 4.20 - 5.4); - HGB (hemoglobin) 5.9 (normal reference range 12.0 - 16.0); - HCT (Hematocrit) 18.3 (normal reference range 36 - 48%); and - PLT (Platelet) 44 (normal reference range 140 - 440). Review of past lab results revealed Resident #67's monthly WBC ranged from 5.8 in October 2009 to 6.4 on 02/22/10. The hemoglobin ranged from 9.2 in October 2009 to 8.6 on 02/22/10. The hematocrit ranged from 29.0 in October 2009 to 27.7 on 02/22/10. The platelets ranged from 188 in October 2009 to 222 on 02/22/10. -- Review of the interdisciplinary progress notes for 04/23/10 at 10:45 p.m. revealed Resident #67 was admitted to the hospital with [REDACTED]. Review of the interdisciplinary progress notes for 04/30/10 at 1:00 p.m. revealed the resident's medical power of attorney representative (MPOA) stated he had found placement for this resident at another facility, which had a private room the resident needed, and she would be transferred there following the hospital discharge. -- Interview with the administrator, on the early afternoon of 12/16/10, revealed a CBC report could not be located from either of the two (2) hospitals for March 2010. | 2014-04-01 | ||
| 11352 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 279 | D | I2SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to develop care plans, for one (1) of thirteen (13) sampled residents and one (1) resident of random opportunity, to reflect each resident's needs and the services being furnished to attain or maintain the resident's highest practicable physical well-being. One (1) resident had a physician's orders [REDACTED]. Another resident had sustained an injury when she spilled hot chocolate on herself, and no mention of this was made on the care plan in order to prevent another such incident. Resident identifiers: #8 and #13. Facility census: 54. Findings include: a) Resident #8 During a random tour of the facility on 08/18/09 at 2:00 p.m., observation found Resident #8 in her bed with side rails up on both sides. Review of the resident's medical record disclosed that, although the resident did have a physician's orders [REDACTED]. b) Resident #13 A review of the accident / incident reports and nursing notes found, on 06/08/09, Resident #13 "fell asleep before breakfast in dining room with hot chocolate in her hand and spilled hot chocolate in her lap." The resident's upper and inner thighs were red, with [MEDICATION NAME][MEDICAL CONDITION] the resident's upper inner bilateral thighs. When interviewed on 08/19/09 at 10:00 a.m., the resident related she was not sure whether she fell asleep or her fingers / hands were not good at holding things as well as before, and she was not sure exactly how the incident happened. She did not think the staff was doing anything differently since the incident occurred related to how she received hot liquids. A review of the resident's current care plan failed to find anything addressing how to promote resident safety with respect to drinking hot liquids without becoming burned. . | 2014-04-01 | ||
| 11353 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 309 | E | I2SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three (3) of thirteen (13) sampled residents and three (3) residents of random opportunity. One (1) resident was hospitalized with a toxic level of medication, and no follow-up labs were completed after the resident's return to the facility. Five (5) residents were observed with side rails up and had no physician's orders for the use of side rails and no mention of their use in the plan of care. Resident identifiers: #40, #43, #15, #52, #30, and #41. Facility census: 54. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 08/17/09, disclosed the resident was admitted to the facility on [DATE] from Health South following a [MEDICAL CONDITION] hip. At the time of admission, the resident was receiving the medication [MEDICATION NAME] 0.25 mg every day for the [DIAGNOSES REDACTED]. On 07/12/09, the resident was noted in nursing notes to be nauseous and having an episode of vomiting. The resident's son insisted she be transferred to the emergency room , from which she was admitted to the hospital with [REDACTED]. The resident returned to the facility on a decreased dose of [MEDICATION NAME] (0.0625 mg) and a potassium supplement on 07/20/09. A document entitled "Physician's Orders", received from the hospital, displayed an order which stated: "Dig ([MEDICATION NAME]) level next week at The Madison." The hospital discharge summary referenced above stated, "Check her [MEDICATION NAME] level within one week and then do it every month thereafter until she is stable and then she can do it once or twice per year." Further review of the record, on 08/17/09, divulged no evidence that a [MEDICATION NAME] level had been obtained since the resident's return to the facility. The facility's director of nurses (DON), when interviewed on 08/18/09 related to this finding, stated the resident's attending physician had not ordered a [MEDICATION NAME] level when the resident returned or at any time since she returned. The DON further stated it was not facility practice to carry out orders from a physician who had cared for the resident during hospitalization unless the attending physician concurred. A confidential interview with two (2) facility nurses related to this finding, on the afternoon of 08/18/09, disclosed that both nurses were not comfortable with no recheck of the resident's [MEDICATION NAME] level, and both felt the attending physician should have been questioned specifically about an order for [REDACTED]. The resident's physician was contacted on the afternoon of 08/18/09, and an order was received to obtain a [MEDICATION NAME] level for this resident. b) Resident #43 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #43 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. c) Resident #15 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #15 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. d) Resident #52 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #52 in bed with side rails up on both sides of the bed. The medical record of this resident disclosed that, although the resident had a pre-written document on his record with "Side rails up when in bed" checked, the document was signed only by a facility nurse; the resident's physician had not signed the order. When reviewed, no mention of the use of side rails was made in the plan of care for this resident. e) When interviewed on 08/18/09 at 2:45 p.m., the assistant director of nurses stated all residents who were using side rails in the up position should have a current physician's order. f) Resident #30 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a low position, and there were safety mats on the floor. Review of the August 2009 physician's orders found the resident was to use half side rails for "turning and positioning". A review of the side rail assessment, dated 04/11/08 and revised on 11/04/08, 12/11/08, 02/10/09, 03/10/09, 04/08/09, 05/01/09, 06/06/09, 07/12/09, and 08/12/09, found each time the assessment was updated, there were no changes with a only comment indicating the resident used half rails as an enabler. There were no comments on the side rail assessment as to how the assessment was completed or whether the resident was observed in order to complete the assessment. Documentation on the front of the assessment stated, "The resident had intermittent confusion, was able to get out of bed safely with assistance, had a history of [REDACTED]." A fall risk assessment, dated 07/26/09, indicated the resident was rated a "10" or at high risk for falls. The mini mental status exam, dated 11/02/08, indicated the resident had severe dementia. The minimum data set assessment, dated 08/06/09, indicated the resident has fallen within the last thirty (30) days, used the side rails for bed mobility / transfer, required extensive assistance of one (1) for bed mobility, and was totally dependent on one (1) person for transfer. The most recent care plan, dated 05/30/09, indicated the resident was at risk "for falls related to history of falls, lack of safety awareness related to dementia", but it did not address the use of side rails in the care plan. A confidential staff interview, on the afternoon of 08/18/09, found the resident was unable to use the side rails and often resisted care by staff. When questioned regarding the resident's ability to hold onto the side rails during care, the staff member indicated the resident only did this occasionally. During an interview with the director of nursing on 08/19/09 at 2:30 p.m., she indicated the resident's ability to use the side rails varied. g) Resident #41 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a medium height position. A side rail assessment, completed on 05/11/09 and revised on 06/07/09, 07/12/09, and 08/12/09, reflected the resident did not use side rails. The 06/12/09 minimum data set assessment indicated the resident used side rails for mobility / transfer, with the self-performance of bed mobility and transfers requiring the extensive assistance of one (1) staff member, and a fall having occurred during the previous thirty (30) days. Review of the physician's orders for August 2009 failed to find physician's orders for the side rails. The current care plan, dated 06/30/09, did not address the use of side rails for the resident. During an interview with the administrator and the DON on 08/19/09 at 2:30 p.m., the DON indicated this resident was not supposed to have side rails in use. . | 2014-04-01 | ||
| 11354 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 159 | D | I2SV11 | Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to individuals who did not have the legal authority to receive this information. This was evident for two (2) of four (4) residents whose personal funds were reviewed. Residents #7 and #57. Facility census: 54. Findings include: a) Residents #7 and #57 A review of the financial information for Residents #7 and #57 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal funds records with the business office manager, on 08/20/09 at 10:00 a.m., found quarterly financial statements were sent to unauthorized representatives for both residents. . | 2014-04-01 | ||
| 11355 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 371 | F | I2SV11 | Based on observation and staff interview, the facility failed to store foods under sanitary conditions. Cold temperatures for milk at 41 degrees F or less were not maintained. Milk from the milk machine temperatures were observed at 42 -50 degrees Fahrenheit (F). This had the potential to affect all residents who drank milk. Facility census: 54. Findings include: a) Observation of preparation of the noon meal, in the dietary department on 08/19/09, found milk in small glasses on a tray in the kitchen. A request was made for one (1) of the cooks (Employee #3) to take the milk temperatures. The first temperature read 50 degrees F, and the second read 45 degrees F. A request was made to take the temperature of milk just after it came from the milk dispenser; this was 45 degrees F, while the external thermometer on the dispenser read 42 degrees F. The temperature of milk dispensed from the machine was measured another thermometer, which read 43 degrees F, while the internal thermometer inside the dispenser read 30 degrees F. Employee #3 and the dietary supervisor were both present. A request was made to review the temperature logs for the milk dispenser. The employee reported she recorded temperatures for both the cooler and the milk dispenser, and it could not be determined whether the temperature logs were for the cooler or the milk dispenser. The temperatures varied from 38 degrees F to 40 degrees F, according to the log, and were listed as measuring the temperature of the refrigerator. . | 2014-04-01 | ||
| 11356 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-08-26 | 323 | G | 3L9811 | . Based on observations, the facility failed to ensure the resident environment remained as free of accident hazards as possible. A treatment cart was found unlocked and unattended on the Blue Ridge hall in the presence of mobile residents. The cart contained items that had the potential to be harmful if ingested or used in a manner other than they were intended to be used. All mobile residents on the Blue Ridge hall had the potential to be affected. Facility census: 114. Findings include: a) Treatment cart - unlocked and unattended During random observations of the facility on 08/24/10 at 7:30 a.m., the treatment cart of Blue Ridge was found sitting outside of the Blue Ridge nurses' station. The cart was not locked, and no staff was in line of sight of the cart. The cart contained a variety of treatment supplies, i.e., a container of Greer's Goo (composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste), Nystop (an antifungal), and a large bottle of 100% Acetone. There would be a potential for adverse reactions should a resident who was sensitive / allergic to Mycostatin or Nystop have contact with the Greer's Goo and / or Nystop. Acetone (http://www.drugs.com/enc/acetone-poisoning.html) has the potential to cause cardiovascular problems (hypotension), gastrointestinal problems (nausea, abdominal pain, vomiting), the nervous system may be affected (seem as though drunk, coma), as might the respiratory system . | 2014-04-01 | ||
| 11357 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 323 | G | 9G3Y12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. . | 2014-04-01 | ||
| 11358 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 323 | G | 777711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. | 2014-04-01 | ||
| 11359 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 250 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to "redirect resident". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were "inappropriate". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 2:21 p.m., the administrator confirmed there was no evidence the facility's social services had initiated a discharge plan related to Resident #35 being transferred to another facility, although the administrator confirmed the facility had started to work on discharging Resident #35 to a facility in Ohio prior to the resident being sent to the hospital on [DATE]. When the administrator was asked for social service notes, she stated, "Yes, there should be some kind of discharge information started and written in the chart, but there is not, and I can't say why it's not there." On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. b) Resident #31 On 12/02/10 at approximately 3:00 p.m., Resident #31 stated he had a medical appointment scheduled for today, but he did not go to this appointment. He said no one told him about the appointment and therefore he did not know he had to go. He said the ambulance attendants came to his room and he did not know why they were there. They informed him they were taking him to a local hospital for some medical test. He chose not to go with them, because according to him, he "did not know anything about an appointment until the ambulance people came to (his) room." The nurse aide (Employee #65) said she came to work at 7:30 a.m. on 12/02/10. She indicated no one had informed her Resident #31 had an appointment on 12/02/10. According to Employee #65, the night shift nurse aide had already made the bed, and the resident had his clothes on for the day. Employee #70 (a registered nurse) said the physician had told Resident #31, on 11/29/10, he had an appointment on 12/02/10. She went on to say things were chaotic on the morning of 12/02/10, and she had forgotten to remind Resident #31 of his appointment today. She agreed the resident the nursing staff should remind residents of their scheduled appointments on the day of the appointment. Resident #31 recently had a computed tomography (CT) scan where lesions and tumors were found on his liver. The appointment on12/02/10 was scheduled for further testing related to these issues. . | 2014-04-01 | ||
| 11360 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 201 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to "redirect resident". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were "inappropriate". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 11:51 a.m., the administrator confirmed it was her preference to not permit the resident to return to the facility. She said, "We told the resident it was not appropriate behavior." On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. On 12/09/10, the responsible party for Resident #35 was contacted and said he was told the facility could not take Resident #35 back because of his behaviors. He said he would rather Resident #35 stay at this facility, since the new facility was located 120 miles away. The responsible party stated, "The facility said they could not take him back." At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. In addition, the care plan did not address the variety of behaviors and/or have interventions which would lead to problem identification and/or correction. There was no evidence to reflect the facility attempted to meet the resident's needs prior to making the determination that they could no longer care for him. . | 2014-04-01 | ||
| 11361 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 279 | E | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, "I really want to get rid of my belly." Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: "Resident wants to lose wt (weight)." Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: "Resident wants to continue to lose wt per her choice due to history of diabetes." An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with an RN (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. c) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to "redirect resident". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. d) Resident #115 During an observations of the dinner meal on 11/29/10 at 6:00 p.m., Resident #115 was observed to be eating in the area designated as the restorative dining area. She was falling asleep. After the others were served, the restorative nursing assistant fed the resident her meal. The medical record, when reviewed on 11/30/10, found Resident #115 had been evaluated by the speech-language pathologies (SLP) for dysphagia with recommendations made on 11/12/10. The SLP stated the goal for this resident was "to decrease risk of aspiration and increase PO (by mouth) intake". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. The resident's most recent interdisciplinary care plan, dated 11/22/10, was reviewed. This plan did not include a restorative nursing care plan, did not identify this resident was at risk for aspiration, and did not include interventions to prevent aspiration and address the resident's swallowing problems as recommended by the SLP. The restorative nursing assistant (Employee #94) was observed feeding this resident lunch at 12:15 p.m. on 12/02/10. The resident had a straw in her milk and was given four (4) to five (5) bites between drinks, instead of two (2) to three (3) bites as recommended by the SLP. The director of nursing (DON), when interviewed at 3:30 p.m. on 12/03/10, reviewed the resident's care plan and verified there was no restorative care plan. . | 2014-04-01 | ||
| 11362 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 319 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to "redirect resident". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were "inappropriate". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. . | 2014-04-01 | ||
| 11363 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 364 | F | GCMN12 | . Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were at appropriate temperatures; however, the cold food (coleslaw) was 51.4 degrees Fahrenheit (F). According to State law, cold foods, at the time of receipt, can measure no more than 50 degrees F. Due to the confusion of getting test trays, another test tray was requested. This one was immediately following the last tray served in the dining room. The tray was tested at 1:15 p.m., with the DM. The hot foods were again at appropriate temperatures; however, the coleslaw was 54.7 degrees F. Upon inquiry, the DM stated the coleslaw was prepared that morning. When asked the size and depth of the pan used to chill the coleslaw, the DM showed the surveyor a 6-inch deep 1/2 steam table pan. This pan was not shallow enough to allow for rapid chilling of cold foods. . | 2014-04-01 | ||
| 11364 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 246 | D | MWZ111 | Based on observation, staff interview, and record review, the facility failed to ensure proper positioning of one (1) randomly observed resident in restorative dining. A resident in a scoot chair was observed eating lunch while the back of his scoot chair was in a reclined position. The reclined position of the chair back interfered with the resident's ability to reach his food. Resident identifier: #189. Facility census: 102. Findings include: a) On 06/29/09 at 12:25 p.m., observation found Resident #189 eating in the restorative dining room. The resident was seated in a scoot chair. The scoot chair's seat was low to the ground, and the backrest was observed to be in a reclined position. The table height was too high for the resident to comfortably reach his food. The resident, who was attempting to feed himself, was having difficulty reaching the food on the table and was spilling some food onto his chest. The resident, when observed on 07/02/09 at 12:30 p.m. in the restorative dining room., was again in the scoot chair seated at the table. The backrest to the chair was observed in a reclined position. The resident was observed having difficulty reaching the food on the table. When interviewed on 07/02/09 at 12:45 p.m., the speech language pathologist (SPL - Employee #17) stated the backrest to the scoot chair was "all the way up". She further stated, "I sometimes put pillows behind his back." The SPL walked over to the chair and raised up the backrest. The resident's medical record, when reviewed at 1:30 p.m. on 07/02/09, revealed a physician's for the scoot chair. A dietary note, dated 06/12/09, reported the resident consumes 59% of meals and requires supervision with meals. . | 2014-04-01 | ||
| 11365 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 240 | B | MWZ111 | Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resident #108 was dependent on staff for all ADLs except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. d) Resident #57 Record review revealed Resident #57 was dependent on staff for all ADLs. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. The water pitcher contained the same amount of liquid, nearly empty, at each check. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. . | 2014-04-01 | ||
| 11366 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 252 | D | MWZ111 | Based on observation and staff interview, the facility failed to provide a clean environment free from unpleasant odors as evidenced by the presence of a persistent odor of urine in a room shared by two (2) incontinent residents. This was evident for two (2) of four (4) sampled residents. Resident identifiers: #6 and #108. Facility census: 102. Findings include: a) Residents #6 and #108 share a room. Observations of the residents' shared room on 06/30/09, at 8:05 a.m., 1:42 p.m., and 2:15 p.m., revealed an unpleasant odor of urine that could be detected immediately upon entering the room. At 8:05 a.m., the odor seemed to be the strongest from Resident #6. At 1:42 p.m., the odor seemed to be coming from an afghan on the bed and the curtain separating the two (2) residents. At 2:15 p.m., the odor of urine was noted also from the wheelchair pad belonging to Resident #108, who had been sitting in the wheelchair. On all three (3) instances, the smell of urine was easily noticeable and could be detected immediately upon entering the room. On 07/01/09 at 11:45 a.m., the distinct odor of urine was detected immediately upon entering the room. During an interview at this time, a nursing assistant (Employee #93) stated she and other aides had noticed a bad smell in the room yesterday and, subsequently, Resident #108's mattress was changed. After the floor was mopped and the resident was showered, they still noticed the odor. She stated she did not believe the odor was coming from the pad in Resident #108's wheelchair, but she agreed she could smell the odor of urine in the curtain separating the residents. She immediately notified housekeeping. The housekeeping, upon arrival, smelled the curtain and also agreed it smelled like urine. She said they do terminal cleaning once every month, which includes taking down the curtains and washing them. She said Resident #6 will yell and throw things when that curtain is removed, as she always wants it pulled. She related she would use the second curtain in the room as a divider between the two (2) beds and take the malodorous curtain down and wash it today. . | 2014-04-01 | ||
| 11367 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 242 | D | MWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, policy review, staff interview and record review, the facility failed to ensure one (1) of twenty-eight (28) Stage II sampled residents receive bi-weekly showers per resident request. Resident #133, who had an intestinal infection, reported she did not receive bi-weekly showers as requested, due to facility's infection control policy regarding [MEDICAL CONDITIONS] infection. Resident identifier: #133. Facility census: 102. Findings: a) Resident #133 Resident #133, when interviewed on 06/30/09 at 10:00 a.m., reported she has not been able to take a shower and get her hair washed for the past two (2) weeks. The resident stated she has an intestinal infection, and staff told her she could not take a shower due to the infection. Resident #133 stated, "This makes me feel dirty and my hair looks terrible." The director of nurses (DON - Employee #20) provided a copy of the facility's policy titled "[MEDICAL CONDITION] Protocol" on 07/01/09. Review of this, at 1:45 p.m. on 07/01/09, found no limitations on a resident's shower schedule during active infection. On 06/30/09 at 11:00 a.m., a licensed practical nurse (LPN - Employee #127), when interviewed, stated, "Residents with [MEDICAL CONDITION] do not get showers due to loose stools." On 07/01/09 at 2:45 p.m., the DON stated residents with [MEDICAL CONDITION] infection can have showers, and it is not the facility's policy to hold showers for residents with [MEDICAL CONDITION] infection. The DON further stated she needed to educate her staff regarding the current policy. Resident #133's medical record, when reviewed on 07/01/09 at 3:00 p.m., revealed a care plan for diarrhea dated 06/09/09. The interventions listed did not include withholding showers until the intestinal infection resolved. . | 2014-04-01 | ||
| 11368 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 431 | E | IFJQ11 | Based on an observation and staff interview, the facility did not ensure that two (2) of two (2) treatment carts were entered only by authorized personnel. A nursing assistant was permitted to have a key to open both treatment carts, which contained supplies and topical medications prescribed to residents by the physician. Facility census: 53. Findings include: a) An observation, on 03/18/09 at 10:00 a.m., revealed a nursing assistant (NA) was assisting the treatment nurse with resident treatments on 200 hall of the facility. The NA was observed using a key to enter the treatment cart and remove treatment supplies. An interview the NA, on 03/18/09 at 10:30 a.m., revealed she assisted the treatment nurse and was permitted to have a key to open both treatment carts. She also stated she would retrieve the necessary supplies and treatments (which would include physician-ordered topical medications) for the nurse. . | 2014-04-01 | ||
| 11369 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 225 | D | IFJQ11 | Based on facility record review and staff interview, the facility failed to make reasonable efforts to uncover criminal histories of two (2) sampled employees, by failing to conduct criminal background checks in all States in which these employees had previously worked. Employee identifiers: #1 and #4. Facility census: 53. Findings include: a) Employee #1 A review of the personnel file of Employee #1, who was hired on 01/21/08, revealed she possessed a nursing license from the Commonwealth of Pennsylvania, and information on her her employment application indicated prior work history in that State. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. b) Employee #4 A review of the personnel file of Employee #4, who was hired on 12/23/08, revealed prior work history in the State of Ohio. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. . | 2014-04-01 | ||
| 11370 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 314 | G | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident sitting in a chair in front of the nurse's station; at 2:15 p.m., staff assisted the resident to bed to be seen by the physician. The chair in which the resident sat was wooden with a curved back and a small flat cushion built onto the chair seat. Review of physician's orders [REDACTED]. On 03/18/09 at 11:30 a.m., observation again found the resident sitting in the wooden chair in front of the nurse's station. During a subsequent interview at 12:05 p.m. on 03/18/09, the treatment nurse (Employee #80) was asked if the small flat cushion which was built onto the resident's chair was adequate as a pressure relieving device, and she stated it was not adequate. . | 2014-04-01 | ||
| 11371 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 329 | D | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure the medication regimen of one (1) of ten (10) sampled residents was free of unnecessary drugs. Resident #21, who was receiving 2 mg a day of [MEDICATION NAME] (greater than the maximum daily dosage recommended for geriatric residents), was exhibiting no behaviors for which the medication was originally ordered, had the medication held on several occasions due to sleeping, and had no attempted gradual dose reduction for ten (10) months. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 A review of the resident's medical record indicated this [AGE] year old female was admitted to the nursing facility on 05/07/08, with a physician's orders [REDACTED]." The resident continued to the present to receive the original dose [MEDICATION NAME] 0.5 mg four (4) times a day, for a total of 2 mg a day. A review of the facility's behavior record indicated that, for the months of February 2009, January 2009, December 2008 , November 2008, and October 2008, the resident did not exhibit any behaviors. The behaviors identified on this record for monitoring included agitation over need to leave and exit-seeking behavior. A review of the physician's progress notes revealed that only one (1) entry addressing the [MEDICATION NAME], dated 11/25/08, in which the physician indicated, "Continue [MEDICATION NAME] less overall anxiety and less of a fall risk at present." Observations of the resident, on 03/11/09 at 3:30 p.m. and 03/12/09 at 11:00 a.m., revealed the resident sitting in a wheelchair with the staff moving the resident to other locations in the facility. An observation of the resident, on 03/16/09 at 10:30 a.m.. revealed the resident lying in bed sleeping. Later at 2:30 p.m., the resident was again observed lying in bed sleeping. A nursing note, dated 02/26/09 (no time was documented), indicated the resident was lethargic related to not sleeping most of the night. The resident's [MEDICATION NAME] was held for the 1:00 p.m. dose. On 02/27/09 at 9:00 a.m., a nursing note indicated the resident was sleeping and the breakfast tray was held. On 03/01/09 at 9:00 a.m., a nursing note again indicated the resident was sleeping and the breakfast tray was held. A review of the CMS Appendix N for unnecessary medication revealed the recommended daily dose for the geriatric resident for the short acting benzodiazepine drugs ([MEDICATION NAME]) was 0.75 mg. A gradual dose reduction should be attempted at least twice within one (1) year. Resident #21 was receiving 2 mg a day and with no attempted dose reduction for ten (10) months. . | 2014-04-01 | ||
| 11372 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2010-12-11 | 371 | F | RUPW11 | . Based on observation and staff interview, the facility failed to assure that two (2) male dietary aides wore effective hair restraints to prevent potential contamination of food by facial hair. This unsanitary practice had the potential to affect all residents receiving an oral diet. Facility census: 80. Findings include: a) An inspection of the dietary department, during the noon meal on 12/11/10 at 12:20 p.m., noted one (1) male dietary aide (Employee #3) was assisting with the service of the noon meal. Observation found Employee #3 had approximately 1/2 inch hair growth on his lip and chin with no beard guard in use to prevent his facial hair from potentially contaminating the food being served. Further observation found another male dietary employee (Employee #4) making peanut butter and jelly sandwiches in an adjacent room. Observation found Employee #4 had facial hair on his lip, chin, and along his jaw with no beard guard in place. When asked why he was not wearing a hair restraint on his beard and mustache, he stated that he had only worked there about three (3) weeks and had never been told he needed to wear anything on his face. | 2014-04-01 | ||
| 11373 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-01-13 | 441 | E | JK1V11 | . Based on observation, staff interview, and a review of the facility's handwashing policy and procedures, the facility failed to ensure four (4) of nine (9) nursing employees observed washed their hand in accordance with acceptable hand hygiene practices per the facility's handwashing policy. Employees #102, #27, #71, and #155 were observed to turn off the faucet with their hands before drying their hands and without obtaining a clean paper towel to turn off the water. This had the potential to affect any resident receiving care from these employees after their hands became recontaminated from contact with the water faucet. Resident identifiers; #39, #115, #36, and #22. Facility census: 132 Findings included: a) Employee #102 During observations made on 01/12/11 at 1:30 p.m., a registered nurse (RN - Employee #102) was observed while washing her hands and after providing perineal care to Resident #39. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for two (2) of three (3) handwashing observations for this employee. -- b) Employee #27 During observations made on 01/12/11 at 1:45 p.m., a nursing assistant (Employee #27) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) of two (2) handwashing observations for this employee. -- c) Employee #71 During observations made on 01/12/11 at 1:45 p.m., a licensed practical nurse (LPN - Employee #71) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) observation for this employee. -- d) Employee #155 During observations of incontinence care on 01/12/11 between 3:10 p.m. and 3:40 p.m., a nursing assistant (Employee #155) was observed assisting with the care of Residents #36 and #22. She washed her hands, turned off the sink faucet with her hand, and then proceeded to dry her hands with a paper towel and put it in the trash. -- e) Review of the facility policy / procedure on handwashing (dated 01/20/10) revealed, in Section C, Item #3, that after washing hands, staff was to use a paper towel to turn off the faucet. -- f) During an interview on 01/13/11 at 10:30 a.m., the director of nursing (Employee #171) reported her expectation that all employees were to follow the facility's handwashing policy and procedure and use a paper towel to turn off the faucet. | 2014-04-01 | ||
| 11374 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-01-05 | 257 | E | TDRO11 | . Based on observation, confidential family interview, confidential resident interviews, and staff interview, the facility failed to maintain an environment with temperatures that were comfortable for the residents. Residents expressed that it was often cold in the front hallway area of the facility that leads to the outside. This was an area frequented by residents and visitors, and persons had to pass through this area to access the activity room, the dining area, and the therapy room. The uncomfortably cold temperature of this area had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During a tour of the facility on 01/03/11 beginning at 1:00 p.m., the temperatures in different areas of the facility were measures, and all areas were found to be above 72 degrees Fahrenheit (F) except the front lobby. The maintenance supervisor (Employee #3) was asked to place a thermometer in this area, so the temperature could be monitored in the hall. Using the facility's own thermometer, the temperature in that hallway at that time was 68 degrees F. Observation also found the heater on the hall in that area was not turned on at that time. - A confidential family interview, conducted on the afternoon of 01/03/11, revealed the facility's temperatures fluctuated a lot, and it was often very cold in this hallway. She stated her mother, who often sites in the hallway, gets very cold, and staff does put a blanket on her, but she would feel the end of her mother's nose and find it to be "cold as ice". - Confidential interviews with alert and oriented residents identified six (6) residents who felt the ambient temperature of this area was uncomfortably cold. One (1) resident stated, "When it is real cold outside, you can not hardly stand to come through that area, but you have to go through it to get to the dining room. Then you are cold when you get in the dining room, because you came through that cold air." Another resident commented that it was very cold in the area when it is real cold outside. One resident said it was cold there and she just tried to hurry through that area and hoped that nothing slowed her down when it is cold. Another resident reported her room was nice and warm, and sometimes she doesn't want to come up front, because she has to go through that cold area. "Sometimes you have a hard time getting through if it is congested, and there are a lot of people in that area. She stated, "Sometimes there's a lot of action going on in that area, and you can't get through very fast." She did not like to linger in that area because of the cold temperature. - Observations of the front lobby area, from 01/03/11 to 01/05/11, found the door was opened very frequently for visitors, the ambulance, and for some deliveries. On the days of the observations and interviews, the exterior temperature was 41 degrees F, while the interior temperature of this area only got up to 68 degrees F. - During an observation on 01/04/11 at 10:00 a.m., Resident #14 was found sitting in front hallway. This resident was dependent on the staff for mobility, and staff had parked her in the front hallway in her wheelchair. At 10:01 a.m., the temperature of the resident's room, where she had been before being brought to the front hallway, was found to be 80 degrees F. Resident #14 was transported from a room measuring 80 degrees to the front hallway measuring 68 degree F. Resident #14 was observed sitting in this hallway until 11:15 a.m. She did have a blanket laying over her, but the air was still cool to breathe and cool on her face after having previously been in a really warm room. This resident was confused and did not communicate; she could not have told staff that she was cold or ask anyone to move her to another area. - During an interview with Employee #3 on 01/04/11, he verified this area was only warmed up to 68 degrees F with the extra wall heater running. He also verified that, when it was really cold outside, this area was difficult to keep warm, and this was where the residents liked to sit. He verified that, with only one (1) single door in this area leading to the outside, when it was outside outside of the facility, this hallway would get cold every time the door was opened. . | 2014-04-01 | ||
| 11375 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-01-05 | 323 | D | TDRO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure the resident environment was free of accident hazards, by applying elevated half side rails to the bed of one (1) of seven (7) residents without first determining these half rails were necessary and safe for use. The facility assessed Resident #43 for the need for side rails on his bed, and his most recent assessment revealed the use of side rails was not indicated. The resident was observed, on 01/05/11, to have half side rails up. This resident was confused, he required staff assistance with transfers and mobility, and he had a history of [REDACTED]. Resident identifier: #43. Facility census: 57. Findings include: a) Resident #43 Observation of Resident #43, on 01/05/11 at 10:00 a.m., found him in bed with a half side rail in the elevated position. The nursing assistant (NA - Employee #29) caring for Resident #43 was interviewed at 10:05 a.m. on 01/05/11, regarding the use of side rails on this resident's bed. This employee stated Resident #43 used side rails to turn and reposition himself in bed. When asked how she determines who was suppose to use bed rails, she stated that the rails were secured down and could not be raised on the beds of residents who were not to use the rails. Review of Resident #43's medical record found a side rail assessment completed on 11/01/11. This assessment indicated the resident did not meet the criteria for the use side rails. Further review of the medical record revealed his [DIAGNOSES REDACTED]. In an interview at 1:00 p.m. on 01/05/11, the director of nursing (DON - Employee #70) identified that Resident #43 should not have side rails used on his bed. She stated that he was confused and he was not supposed to have side rails. She verified the assessment completed on this resident showed that side rails were not indicated for this resident and, therefore, the side rails should not be used. | 2014-04-01 | ||
| 11376 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 157 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the electronic medical record, staff interview, family interview, and incident report review, the facility failed to immediately inform the legal representative when one (1) of nine (9) sampled residents was involved in an incident requiring physician intervention. Resident #100, who had a history of [REDACTED]. After the son intervened, staff contacted the physician and Resident #100 was subsequently sent to the hospital where she was diagnosed with [REDACTED]. Facility census: 115. Findings include: a) Resident #100 On 11/16/10 at approximately 9:00 a.m., a family interview revealed Resident #100's son, who was also her legal representative, did not receive notification that his mother fell on [DATE] until he came to the facility on [DATE] and found a bruise on her shoulder. - Documentation on an incident report dated 10/16/10, when reviewed on 11/16/10 at approximately 1:00 p.m., revealed the nurse wrote, "As I was starting up the hallway, to do my med pass heard resident in (room #) yelling out. When entered the room and walked to her side (sic) she already started out of the bed on her arms before I got to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side." Documentation on the report related to notification of the resident's responsible party found the son was not notified of the fall until 5:00 p.m. on 10/17/10. - Review of Resident #100's electronic medical record, on 11/16/10 at approximately 2:00 p.m., revealed a nursing progress note identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.) which stated, "As I was walking up the hallway to do my med pass. Writer heard resident yelling out. When entered the room and walked to her side. She already started out of the bed on her arms before I could get to her; the bottom half slithered out and onto the mat. Asked resident if she could get up and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist resident back into bed. When I had given the resident her meds which I had already had in the room with me at that time (sic). I assessed and did not see any injuries at this time. Resident did not complain of any pain nor distress noted." A nursing progress note dated 10/17/10 at 18:20 (6:20 p.m.) stated, "At 5pm (sic) son reported to this nurse that he found a bruise on resident's shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray. B/P 123/69 Temp 98.6 R18 P87 O2 sats 95%. Called Life Ambulance but had no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm." - A nursing progress note dated 10/17/10 at 23:46 (11:46 p.m.) stated: "Resident returned to facility at this time, via ambulance stretcher alone, family did not accompany her at this time, received report from d/c nurse at (name of hospital), she stated she has a FX (fracture) to her right clavicle and will be returning with an immobilizer to right arm...." - On 11/17/10 at approximately 1:00 p.m., the administrator and director of nursing agreed the facility should have contacted the resident's son on 10/16/10 after the fall occurred. . | 2014-04-01 | ||
| 11377 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 441 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the facility failed to fully implement appropriate measures to control the spread of scabies and to prevent possible re-exposure and re-infestation, in accordance with the facility's infection control policies and procedures and accepted standards of professional practice. These practices had the potential to result in more than minimal harm to all residents. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the handling of an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... "5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. "5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... "5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. "5.4.1 - Label bag 'Do Not Open until ____ (date).'" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: "To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: "Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. "Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..." (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, "I swear everything was labeled." At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's "Scabies Case / Contact Line-Listing Form: Patients: " submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's "Scabies Cleaning Timeline - 11/5/10", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): "Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]." (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) . | 2014-04-01 | ||
| 11378 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 490 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the governing body failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical well-being of all residents and others. The facility's administration failed to oversee and ensure the infection control policies and procedures were implemented as written to manage an outbreak of scabies and prevent transmission to others inside and outside the facility. This practice has the potential to cause more than minimal harm to all residents, staff, and visitors. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the governing body's failure to ensure the facility responded appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... "5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. "5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... "5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. "5.4.1 - Label bag 'Do Not Open until ____ (date).'" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: "To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: "Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. "Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..." (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, "I swear everything was labeled." At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's "Scabies Case / Contact Line-Listing Form: Patients: " submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's "Scabies Cleaning Timeline - 11/5/10", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): "Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]." (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) . | 2014-04-01 | ||
| 11379 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 520 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... "5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. "5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... "5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. "5.4.1 - Label bag 'Do Not Open until ____ (date).'" - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, "I swear everything was labeled." At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's "Scabies Case / Contact Line-Listing Form: Patients:" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's "Scabies Cleaning Timeline - 11/5/10", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) In a written statement provided by the DON on 11/17/10, the facility held their last quarterly QAA committee meeting on 07/02/10. During that meeting, the committee discussed the procedures to be taken in a scabies outbreak. One (1) item listed on the written statement was that the facility would bag all items in resident rooms, label, and date them for when the bags are to be opened. The facility did not list a monitoring action to ensure that all procedures were implemented during a scabies outbreak. | 2014-04-01 | ||
| 11380 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 309 | G | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have "slithered" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a "late entry" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising was discovered by the family. This bruise, which extended from her neck, across her shoulder, and down her right arm, was readily visible to the family (as the resident was wearing a hospital gown), and it was turning black in color when found by the family on 10/17/10. The facility had no knowledge of this bruise until the family brought it to their attention. Only after the son intervened, did the facility contact the physician, and Resident #100 was later diagnosed with [REDACTED]. Although it could not be ascertained whether the fracture was sustained during the fall on 10/16/10, during the transfer back to bed after the fall on 10/16/10, or during a fall that occurred at an earlier date, the facility failed to identify the presence of the injury and obtain medical intervention until after the resident's family intervened. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, "As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)." This report, which was signed as having been prepared by Employee #128 on 10/16/10, contained no assessment information in the section titled "Initial Assessment", which prompted the assessor to record information such as vital signs and an examination for any changes in the resident's range of motion. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - "Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve." - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a "late entry", written by Employee #128, an LPN - "As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted." - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - "At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm." - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - "resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..." There were no entries between the note identified as a "late entry" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. -- 3. A review of the nursing notes after the resident's return to the facility on [DATE] revealed an entry dated 10/18/10 at 08:47 (8:47 a.m.), written by Employee #34, stating, "Late entry for 10/17/2010. During med pass at 10am (sic) this nurse ask (sic) resident if she was having any pain. Resident denied pain. Resp (respirations) even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed dose of Tylenol (sic) and ask (sic) resident again if she had any pain and she denied pain. Administrated schelduled (sic) medication at 2:30pm (sic) and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Ask (sic) resident how if (sic) she was feeling ok and she stated she was 'fine'." All of this information was entered into the record on the morning after the resident returned from the hospital, after having been diagnosed with [REDACTED]. -- 4. review of the resident's medical record revealed [REDACTED]. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers), and a test for standing balance could not be attempted at that time. Review of the resident's care plan revealed a problem statement related to the resident's risk for complications associated with diabetes. The first intervention listed to address this problem was: "Assess skin integrity daily with care and report abnormalities." Review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: 10/16/10 on evening shift - total dependence for transferring by two (2) nursing assistants; total dependence with bathing (partial bed bath); extensive physical assistance with dressing by two (2) nursing assistants; and total dependence for personal hygiene by one (1) nursing assistant. 10/16/10 on night shift - extensive physical assistance for transferring by two (2) nursing assistants; extensive physical assistance for bathing by two (2) nursing assistants (sponge / bed bath); and total dependence with dressing by one (1) nursing assistant. No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and no information was available any ADL assistance provided on the evening shift, because staff recorded "OOF" (out of facility) for the entire shift, even though the resident was not transferred to the hospital until 6:20 p.m. on 10/17/10. (See also citation at F514.) The performance of transferring, dressing , bathing, and/or personal hygiene on these shifts for this dependent resident would have provided opportunities for staff to have observed bruising as it developed on the resident's right neck, shoulder and upper arm, especially while she was wearing a hospital gown (as had been observed by the family on the evening of 10/17/10). -- 5. Review of an "unusual occurrence", self-reported by the administrator to the State survey and certification agency on 10/18/10, revealed the following: "On 10/17/10 MPOA of (Resident #100) had a concern about the bruise on her left shoulder and questioned if it was fractured. The administrator was notified by the MPOA that he needed to see it. (Note: The reference to the left shoulder appears to be a mistake as the nursing note for 10/17/10 reflected the son found a bruise on the resident's right shoulder.) "The Resident (sic) is DNR (do not resuscitate), limited treatment, Hospice. Has a history of multiple falls related to behavior issues (sic). According to physician determination of capacity, the resident lacks capacity to make her own healthcare decisions due to Dementia, Stage 7. "On 10/16/10 at approximately 9:00pm (sic) the resident was observed to have been 'slithering out and onto the mat. Asked resident if she could get up and as she attempted went down onto her right side. Resident was assessed and the nurse did not see any injuries at this time. Resident did not complain of any pain nor distress noted. (No quotation mark was present to indicate where the quoted material ended.) "During med pass at 10am (sic) on 10/17/10, the nurse asked resident if she was having any pain. Resident denied pain. Respirations were even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed does of Tylenol and ask resident again if she had any pain and she denied pain. Administered scheduled medication at 2:30 pm and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Asked resident if she was feeling ok and she stated she was 'fine.' "On 10/17/10 at approximately 5:30pm (sic) the family visited and voiced concerns and wanted her to be sent to the Hospital (sic) for an evaluation. The Clavicle (sic) was fractured. The resident was returned to the facility with continued meds. Resident is being observed and monitored." -- 6. A telephone interview with the administrator, on 12/08/10 at approximately 9:30 a.m., revealed Resident #100 received hospice services. She had a physician's orders [REDACTED]." According to the administrator, Hospice Care had ordered this, because the family felt the multiple falls the resident was having may have been related to her having untreated pain. The administrator also said he had observed the resident, after the family contacted him on the evening of 10/17/10, and did not find her to be in any pain. -- 7. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. (See also citation at F157.) -- 8. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED].#100 had the following documented events in the days prior to 10/16/10: - 10/01/10 at 6:45 p.m. - "Resident was in shower room with CNA when CNA attempted to stand resident to dry her off. When CNA was drying resident, resident decided to sit on floor. Resident was lowered to floor by CNA." - 10/10/10 at 3:00 p.m. - "Resident sitting in WC (wheelchair); went to stand up to go to room. She went down to the floor." - 10/11/10 at 10:30 a.m. - "Resident sitting in w/c (wheelchair) in hallway by nurses (sic) station - noted to roll out of w/c to floor." - 10/11/10 at 11:15 a.m. - "Resident noted to be scratching at right forearm then scab noted in hand - bleeding noted from right forearm." - 10/11/10 at 3:00 p.m. - "Resident found curled up on safety mat next to bed. Stated 'I'm hiding they are going to kill me.' When asked if she fell or climbed she stated she climbed to hide from people trying to kill her. " - 10/12/10 at 8:45 a.m. - "Pt (patient) was sitting in wheelchair in dining room requesting to 'go to Bed'. Pt was informed it would be a few minutes. Then pt leaned forward and fell on to floor." - 10/13/10 at 5:15 p.m. - "Resident was sitting at nurses (sic) station in w/c when resident put herself in the floor. When asked why she stated she was hiding cause (sic) they were gonna kill her." The director of nursing (DON) reported, at about 11:45 a.m. on 12/09/10, that most of the time Resident #100 did not have any injuries from these incidents but that bruising would appear later. -- 9. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had "slithered" the bottom half of her body onto the mat. Following this, she went to get assistance from two (2) nurse aides (Employees #29 and #129). Employee #128 reported she believed the three (3) of them used a sheet to transfer the resident back into her bed; however, she was not positive that this was how the transfer back to the bed occurred. Employee #128 stated she did not consider this event a "fall" and, as a result, she did not complete an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) (NOTE: According to Appendix PP of the State Operations Manual promulgated by the Centers for Medicare & Medicaid Services, "'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.") Employee #128 commented that she guessed she just forgot to fill out the top initial assessment portion on the report. This section was left blank. She said she asked the resident if she was hurt, and the resident said she was not. She also said she asked the resident if she was in pain, and the resident denied that as well. Employee #128 said she had a concern that the resident may have injured her hip. This concern was due to the fact that she had asked the resident if she could get up after the fall and the resident tried but landed on her right side. The LPN said she assessed the resident's right hip by applying pressure to the area to see if the resident expressed experiencing pain; the resident did not. She denied physically assessing any other part of the resident's right side, and she did not perform any range of motion exercise to any areas on the resident's right side to check for injuries. Employee #128 said she was aware the resident had a bruise to her right shoulder from a previous fall. -- 10. Employee #129 was interviewed by telephone at approximately 1:00 p.m. on 12/09/10; he no longer worked at the facility. He confirmed that he assisted the LPN with getting the resident back to bed on 10/16/10; he said he thought they picked the resident up under her arms to get her back into bed. He reported having no other knowledge of anything pertaining to the fall. -- 11. Employee #34 was interviewed by telephone on the early afternoon on 12/09/10. She acknowledged she was the LPN assigned to work with Resident #100 on 10/17/10, and that she was at the facility when the resident's family arrived and questioned the bruise on the resident's shoulder. She reported she did not know how the bruise got there, but she told the family she thought the resident had fallen on 10/15/10. She stated she told the family they would probably get faster results from having a mobile imaging company perform the x-ray on the resident's shoulder but the family insisted on having the resident sent out to a local emergency room . She related that Employee #128 did not tell her anything about the resident falling on 10/16/10 when she reported to work at 7:00 a.m. on 10/17/10. Employee #34 said Resident #100 acted very pleasant on during the day on 10/17/10. She reported she always asks the residents if they are in pain and said Resident #100 denied being in pain. -- 12. The DON and administrator acknowledged that Employee #128 failed to thoroughly assess Resident #100 following the fall on 10/16/10. However, the DON and administrator reported their beliefs that the facility had provided quality care to the resident and that staff had mainly failed to document their assessments and findings . | 2014-04-01 | ||
| 11381 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 514 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the medical record of one (1) of nine (9) sampled residents was maintained in accordance with accepted standards of professional practice. Resident #100 was observed by a licensed practical nurse (LPN) having "slithered" out of her bed and onto the floor on the evening of 10/16/10. The LPN who witnessed this occurrence (Employee #128), when interviewed on 12/09/10, reported that she did not record an entry in the resident's nursing notes when the event occurred; rather, she recorded an entry in the nursing notes after the family noticed extensive bruising on the resident's shoulder during a visit on the evening of 10/17/10. The note, which was identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.), did not contain any information to alert the reader that it was actually recorded after the fact, at a later date and time. Additionally, review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed blanks where the assigned nursing assistant should have recorded the amount of ADL assistance provided to the resident on the day shift (7:00 a.m. to 3:00 p.m.) on 10/17/10, and staff recorded "OOF" (out of facility) for the evening shift (3:00 p.m. to 11:00 p.m.) on 10/17/10, even though she did not leave the facility until 6:20 p.m. on that date. According to this resident's most recent minimum data set assessment, she was totally dependent on staff for all ADLs. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, "As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)." This report was signed as having been prepared by Employee #128 on 10/16/10. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - "Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve." - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a "late entry", written by Employee #128, an LPN - "As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted." - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - "At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm." - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - "resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..." There were no entries between the note identified as a "late entry" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. (See also citation at F309.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled "5. Legal Documentation Standards": "9. Completeness - Document all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment (including the reason for it). Make sure entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification." - "20. Incidents - When an incident occurs, document the facts of the occurrence in the progress notes. Do not chart that an incident report has been completed or refer to the report in charting." -- 3. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. -- 4. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED]. on 10/16/10 contained no information to alert the reader that the note was not contemporaneously recorded in the electronic medical record at 9:00 p.m. on 10/16/10. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had "slithered" the bottom half of her body onto the mat. Employee #128 stated she did not consider this event a "fall" and, as a result, she did not record an entry in the resident's medical record or generate an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled "5. Legal Documentation Standards": "3. Date and Time on Entries "3.1. Timeliness of Entries - Entries should be made as soon as possible after an event or observation is made. An entry should never be made in advance. If it is necessary to summarize events that occurred over a period of time (such as a shift), the notation should indicate the actual time the entry was made with the narrative documentation identifying the time events occurred if time is pertinent to the situation. "3.2. Pre-dating and back-dating - It is both unethical and illegal to pre-date or back-date an entry. Entries must be dated for the date and time the entry is made. (See section on late entries, addendum, and clarifications). If pre-dating or back-dating occurs it is critical that the underlying reason be identified to determine whether there are system failures. The cause must be evaluated and appropriate corrective action implemented." - "24. Omissions in Documentation - At times it will be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement entries previously written. "0. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. "1. Identify the new entry as a 'late entry'. "2. Enter the current date and time - do not try to give the appearance that the entry was made on a previous date or an earlier time. "3. Identify or refer to the date and incident for which (sic) late entry is written. "4. If the late entry is used to document an omission, validate the source of additional information as much as possible (where did you get information to write late entry). For example, use of supporting documentation on other facility worksheets or forms. "5. When using late entries (sic) document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes." -- 5. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, and she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers). Review of the resident's ADL flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: - No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and - No information was available any ADL assistance provided on the evening shift, because staff recorded "OOF" (out of facility) for the entire shift. This dependent resident was not transferred to the hospital until 6:20 p.m. on 10/17/10 and would have been present to receive ADL assistance from staff throughout the entire day shift and a portion of the evening shift on 10/17/10. | 2014-04-01 | ||
| 11382 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 327 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to: (1) ensure a resident with a gastrostomy feeding tube received all 275 cc free water flushes in accordance with physician orders; (2) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Review of the form titled "ED Nursing Record - Adult Male - PRIMARY ASSESSMENT", in the section titled "EENT" (ears, eyes, nose, throat) was written: "Dried oral secretions (sic) oral membrane". In the section titled "Skin" were circled the words "diaphoresis" and "hot". In the section titled "Cardiovascular" was written (next to the printed word "[MEDICAL CONDITION]") "mild Bilat(eral) leg & arm". Above the nurse's signature was written: "hands / fingers swelled (sic) ..." Documentation on the form titled "ED Nursing Record - Adult Male - General Documentation", under the heading "I & O" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic and "Patient much more alert /p (after) NS (normal saline) Bolus." The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Regarding Maintaining Fluid Balance and Monitoring of Urinary Output Review of the physician's orders [REDACTED]. - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." - "Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)." - "Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional." -- Review of his care plan revealed the following problem statement: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Free H2O, 250ml q 4 hrs, as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident ' s needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift, although there was a physician's orders [REDACTED]. -- Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours." Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, " ...Urinary output >200cc at this time." -- Review of the resident's "Bedside Intake and Output Records" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. . | 2014-04-01 | ||
| 11383 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 224 | G | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Review of the form titled "ED Nursing Record - Adult Male - PRIMARY ASSESSMENT", in the section titled "EENT" (ears, eyes, nose, throat) was written: "Dried oral secretions (sic) oral membrane". In the section titled "Skin" were circled the words "diaphoresis" and "hot". In the section titled "Cardiovascular" was written (next to the printed word "[MEDICAL CONDITION]") "mild Bilat(eral) leg & arm". Above the nurse's signature was written: "hands / fingers swelled (sic) ..." Documentation on the form titled "ED Nursing Record - Adult Male - General Documentation", under the heading "I & O" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic, his abdomen was distended and tympanic, "decubiti" (pressure sores) were present "multi site", and the resident had a [MEDICATION NAME] central line with a dressing labeled "11/9/10". "Patient much more alert /p (after) NS (normal saline) Bolus." In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him ("Start [MEDICATION NAME] when [MEDICATION NAME] complete") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. -- 3. Hospital #2 Records The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 "History and Physical" revealed under the heading "History of Present Illness": "This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..." "In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission." Under the heading "Impressions" were noted: "1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..." Under the heading "Plans" were noted: "1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications." - The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Elevated Temperatures (a) Vitals Summary Report (VSR) A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as "High of 99.0 exceeded". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- (b) Nursing Notes Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - "Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor." - 10/14/10 at 1:47 p.m. - "Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted." - 10/17/10 at 11:30 a.m. - "REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted." - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- (c) Medication Administration Record (MAR) Review of the resident's November 2010 MAR revealed staff initialed having administered "Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- (d) Comparison of VSR, Nursing Notes, and MAR Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (1) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). All entries in the nursing notes between 11/04/10 and 11/16/10 were made by licensed practical nurses (LPNs). There was no evidence of any nursing assessment having been completed by an RN and recorded in the resident's nursing notes. Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. No labs were ordered during this period of intermittent fevers beginning on 11/04/10, in an effort to identify the infectious organism(s) and/or what antibiotic(s) would be effective in treatment. (According to labs collected at Hospitals #1 and #2, the resident had multiple infectious organisms at multiple sites (central line catheter tip, urine, blood, and at the insertion sites of his suprapubic catheter and gastrostomy tube), all of which were resistant to [MEDICATION NAME], meaning the [MEDICATION NAME] that was administered prior to the resident's transfer to Hospital #1 was ineffective in treating these infections.) The only entry made by an RN prior to his transfer to the hospital was recorded at 9:48 p.m. on 11/17/10. It contained no assessment information but stated the resident was transferred to the hospital "unplanned" for evaluation and treatment, after the physician was notified of a "condition change" at 2145 (9:45 p.m.), and an attempt was made to notify the resident's responsible party. -- (2) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (3) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (4) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." -- (5) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (6) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- (e) References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled "Fever": "Fever is the temporary increase in the body's temperature in response to some disease or illness. "... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems - Have a new rash or bruises appear - Have pain with urination - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. - Have recently traveled to a third world country" (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled "Fever: First aid": "Fever is a sign of a variety of medical conditions, including infection. "... Under the arm (axillary) "Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. "... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..." (URL: ) -- (3) According to Drugs.com, in an article titled "How To Take An Axillary Temperature": "What is it? "An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. "Why do I need to check an axillary temperature? "An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... "How do I use a digital thermometer? "Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..." (URL: ) -- (f) Facility Policy Review of the facility's policy titled "3.5 Vital Signs" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled "Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- (g) Care Plans Addressing Vital Signs A review of the resident's care plan revealed the following: (1) A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal were: - "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) - "Administer [MEDICATION NAME] as ordered." (This intervention had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (2) Another problem statement was: "Triple lumen PICC line due to need for IV antibiotics for urosepsis." (This problem statement had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: "(Resident #28) will have no complication related to IV therapy by (sic) x 60 days." (This goal had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, was revised on 11/17/10, and had a "Target Date" of 12/11/10.) One (1) intervention developed to achieve this goal was: "Vital signs q (every) shift." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of the VSR found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 5. Fluid Balance / Hydration Status (a) Physician Orders Review of the physician's orders [REDACTED]. - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." - "Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)." - "Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional." -- (b) Care Plan Addressing Hydration / Fluid Balance Review of his care plan revealed the following problem statement: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Free H2O, 250ml q 4 hrs, as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output | 2014-04-01 | ||
| 11384 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 157 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, and review of information published on the Internet related to the topics of "fever" and "axillary temperature facility failed, for one (1) of five (5) sampled residents, to promptly notify the physician when the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a urinary tract infection [MEDICAL CONDITION]. Resident #28 completed his antibiotic therapy on 11/07/10 and began having intermittent fevers on 11/09/10. Staff did not notify the physician of this until 11/16/10. The resident, who was transferred to a hospital on [DATE], was subsequently diagnosed with [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic, his abdomen was distended and tympanic, "decubiti" (pressure sores) were present "multi site", and the resident had a [MEDICATION NAME] central line with a dressing labeled "11/9/10". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him ("Start [MEDICATION NAME] when [MEDICATION NAME] complete") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 "History and Physical" revealed under the heading "History of Present Illness": "This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..." "In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission." Under the heading "Impressions" were noted: "1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..." Under the heading "Plans" were noted: "1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications." The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR indicated [REDACTED] From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled "Fever": "Fever is the temporary increase in the body's temperature in response to some disease or illness. " ... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. " ... Call your doctor right away if you are an adult and you: ... - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- 6. A review of the resident's care plan revealed the following: A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal included: "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) . | 2014-04-01 | ||
| 11385 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 514 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to maintain clinical records for one (1) of five (5) residents (#28) in accordance with accepted professional standards and practices that are completed, accurately documented, readily accessible, and systematically organized. The facility failed to obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. readings for analysis, tracking, and trending of abnormal findings. The facility also failed to record on the medication administration record (MAR) each time Tylenol was given from an elevated temperature and failed to record on the reverse side of the MAR whether the medication was effective in reducing his temperature. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his minimum data set assessment (MDS 3.0), an abbreviated quarterly assessment with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10. Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as "High of 99.0 exceeded". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- 3. Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - "Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor." - 10/14/10 at 1:47 p.m. - "Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted." - 10/17/10 at 11:30 a.m. - "REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted." - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- 4. Review of the resident's November 2010 MAR revealed staff initialed having administered "Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- 5. Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - " ... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - " ... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature - (b) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - (c) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. - (d) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. | 2014-04-01 | ||
| 11386 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 282 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, policy review, and staff interview, the facility failed to provide services to one (1) of five (5) sampled residents in accordance with the resident's comprehensive plan of care including physician orders, with respect to: monitoring vital signs; providing free water flushes as ordered; monitoring the resident's urinary output to ascertain whether it was necessary to irrigate the resident's suprapubic catheter; monitoring central line and ostomy sites for signs of infection; and providing dressing changes to the central line site as ordered. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a PEG tube), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic, his abdomen was distended and tympanic, "decubiti" (pressure sores) were present "multi site", and the resident had a [MEDICATION NAME] central line with a dressing labeled "11/9/10". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him ("Start [MEDICATION NAME] when [MEDICATION NAME] complete") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident ' s care plan revealed the following: (a) A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal were: - "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) - "Administer [MEDICATION NAME] as ordered." (This intervention had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (b) Another problem statement was: "Triple lumen PICC line due to need for IV antibiotics for urosepsis." (This problem statement had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: "(Resident #28) will have no complication related to IV therapy by (sic) x 60 days." (This goal had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, was revised on 11/17/10, and had a "Target Date" of 12/11/10.) One (1) intervention developed to achieve this goal was: "Vital signs q (every) shift." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of the weights and vitals summary report found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 4. Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours." Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, " ...Urinary output >200cc at this time." Review of the resident's "Bedside Intake and Output Records" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. -- 5. Review of a facility table titled "Infusion Maintenance Table" (with a revision date of 04/01/10), revealed dressing changes for non-tunneled central venous access devices (including [MEDICATION NAME] central lines) are to be performed twenty-four (24) hours after insertion, then weekly and PRN. (It should be noted that the facility used "PICC line" in documentation prior to his return to the facility on [DATE] to describe what a [MEDICATION NAME] central line.) -- Further review of the resident ' s care revealed: One (1) problem statement said: "Triple lumen PICC line due to need for IV antibiotics for urosepsis." (This problem statement had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: "(Resident #28) will have no complication related to IV therapy by (sic) x 60 days." (This goal had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, was revised on 11/17/10, and had a "Target Date" of 12/11/10.) One (1) intervention developed to achieve this goal was: "Sterile dressing change per policy and prn (as needed)." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of Resident #28's treatment sheet, used for recording care provided to central-line catheters, found it was marked to indicate scheduled dressing changes were to be completed on 11/02/10, 11/09/10, and 11/16/10. The dressing change scheduled for 11/16/10 was not initialed by a nurse to indicate it had been completed, in accordance with facility policy and the resident's care plan intervention. Another intervention developed to achieve this goal was: "Inspect site for signs of inflammation, phlebitis, or infiltration q shift." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was inspecting the site of the central line for signs and symptoms of infection in accordance with this care plan intervention. -- Another problem statement was: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Monitor skin around PEG tube site,skin (sic) care and dressing as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) - Review of the monthly recapitulation of physician's orders [REDACTED]. Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was routinely inspecting the site for signs or infection. -- An interview with the assistant director of nursing (ADON - Employee #9), on 12/20/10 at 4:00 p.m., confirmed the form utilized by staff to documented central line dressing changes was not initialed on 11/16/10, which was the date the dressing was due to be changed. She further stated the nursing staff apparently did not change the dressing. -- According to the Hospital #2 "Discharge Summary", when the resident was evaluated in the hospital on the early morning of 11/18/10, the ER physician found pus surrounding his suprapubic catheter and [DEVICE], and his [MEDICATION NAME] catheter tip tested positive for Staphylococcus epidermidis. . | 2014-04-01 | ||
| 11387 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 279 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to develop a care plan to ensure a resident with a gastrostomy feeding tube and a suprapubic catheter, who had a history of [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Review of the form titled "ED Nursing Record - Adult Male - PRIMARY ASSESSMENT", in the section titled "EENT" (ears, eyes, nose, throat) was written: "Dried oral secretions (sic) oral membrane". In the section titled "Skin" were circled the words "diaphoresis" and "hot". In the section titled "Cardiovascular" was written (next to the printed word "[MEDICAL CONDITION]") "mild Bilat(eral) leg & arm". Above the nurse's signature was written: "hands / fingers swelled (sic) ..." Documentation on the form titled "ED Nursing Record - Adult Male - General Documentation", under the heading "I & O" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic and "Patient much more alert /p (after) NS (normal saline) Bolus." The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Fluid Balance and Monitoring Urinary Output (a) Review of the physician's orders [REDACTED]. - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." - "Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)." -- (b) Review of his care plan revealed the following problem statement: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Free H2O, 250ml q 4 hrs, as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the assessment and/or maintenance of the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident's needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift (although there was a physician's orders [REDACTED]. -- (c) An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. . | 2014-04-01 | ||
| 11388 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 281 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and policy review, the facility failed to provide services that meet professional standards of quality for one (1) of five (5) sampled residents (#28). Resident #28, who had a gastrostomy feeding tube and a suprapubic catheter and who had a personal history of urinary tract infections, exhibited an elevated temperature beginning on 11/04/10. On 11/05/10, staff contacted the physician, who ordered a 3-day course of antibiotics ([MEDICATION NAME]) via intramuscular injection (IM). Two (2) days after this first course of antibiotics ended, the resident began (on 11/09/10) to exhibit intermittent elevated temperatures; however, the staff did not promptly notify the physician of this. These temperatures were taken via axilla, which is usually 1 degree Fahrenheit (F) below a temperature taken orally; the temperatures were not monitored at the frequency specified in the resident's care plan; they were not consistently recorded in the same place in the medical record for ready access for analysis, tracking, and trending; and the staff did not always medicate with Tylenol when indicated. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - " PEG tube " or " [DEVICE] " ), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. - The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- (b) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR (to indicate Tylenol was given for an elevated temperature), but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (c) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (d) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." -- (e) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (f) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- 4. References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled "Fever": "Fever is the temporary increase in the body's temperature in response to some disease or illness. "... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled "Fever: First aid": "Fever is a sign of a variety of medical conditions, including infection. "... Under the arm (axillary) "Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. "... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..." (URL: ) -- (3) According to Drugs.com, in an article titled "How To Take An Axillary Temperature": "What is it? "An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. "Why do I need to check an axillary temperature? "An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... "How do I use a digital thermometer? "Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..." (URL: ) -- 5. Review of the facility's policy titled "3.5 Vital Signs" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled "Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- 6. A review of the resident's care plan revealed the following: (a) A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal were: - "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) - "Administer [MEDICATION NAME] as ordered." (This intervention had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. . | 2014-04-01 | ||
| 11389 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 278 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of resident assessment data and physician orders, the facility failed, for one (1) of five (5) sampled residents, to ensure each resident assessment accurately reflected each resident's health status and condition. Resident #28's primary source of nutrition was received via a gastrostomy tube, but his most recent abbreviated quarterly assessment did not identify the presence of this feeding tube. Facility census: 68. Findings include: a) Resident #28 Record review, on 12/20/10 and 12/21/10, included a review of the resident's assessments and physician orders. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. In Section G, the assessor noted Resident #28 was totally dependent on one (1) staff member for eating. In Section K, the assessor noted he did NOT receive any nutrition through tube feeding. Review of the physician's orders [REDACTED]. - "Peg tube: Magna ports 20 Fr. 10cc - FYI - Change when dysfunctional. May use 18 fr 10cc or 20 fr 10cc." This order was originally given on 07/29/09 - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." This order was originally given on 05/18/09. Review of the resident's most recent comprehensive assessment (MDS 2.0) with an ARD of 01/28/10 revealed, in Section K, the assessor did note the presence of a feeding tube, which was used to provide 76-100% of the resident's total daily calories and 2001 or more cc of fluid intake daily. . | 2014-04-01 | ||
| 11390 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2010-12-29 | 329 | D | CYQN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to assure the resident's drug regimen was free of unnecessary drugs. A resident receiving a medication that had the ability to affect her level of consciousness, and which was ordered to treat the symptom of anxiety, was awakened by the nurse by having her face bathed with a cold cloth in order to receive an additional dose of that same medication. Resident identifier: #65. Facility census: 61. Findings include: a) Resident #65 When reviewed on 12/28/10, the closed medical record of Resident #65 divulged the resident had been admitted to the facility in February 2001 and was 80-years old at that time. When transferred to the hospital from the facility on 12/11/10, the resident's weight was noted to be 70 pounds. The resident was noted to have [DIAGNOSES REDACTED]. The resident's record further revealed she suffered with severe breathing problems and frequent episodes of anxiety, possibly associated with the inability to breathe without difficulty. The resident had been receiving the medication Klonopin for anxiety, in varying dosages since the time of admission to the facility. On 12/10/10, a physician's orders [REDACTED]. According to the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to http://www.fda.gov/downloads/Drugs/DrugSafety, the patient medication guide for the medication Klonopin indicated the most common side of the medication is drowsiness. Facility nurse's notes, on 12/11/10 at 10:50:57 a.m., stated, "Klonopin 0.5mg given this am (morning) and resident very hard to awaken. Cold wash cloth applied to forehead and to resident's face. Resident aroused long enough to give meds. Also was unable to feed resident breakfast or to give am (morning) snack..." The resident was not exhibiting the symptom of anxiety for which it was ordered, and she was actually experiencing a decreased level of consciousness prior to the administration of the dose (as stated in the 12/11/10 nurse's note). This documented statement would indicate the evening dose of the medication was unnecessary at that time. On 12/28/10 at approximately 4:00 p.m., the facility's director of nurses (DON), when questioned about this statement of the need to awaken a resident to administer an anti-anxiety medication, could provide no reason for a sleeping resident to be awakened to receive a medication prescribed to treat anxiety. | 2014-04-01 | ||
| 11391 | NELLA'S INC. | 51A010 | 399 FERGUSON ROAD | ELKINS | WV | 26241 | 2010-03-17 | 225 | D | N9NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to immediate report and/or thoroughly investigate allegations of abuse and/or neglect to the appropriate State agencies. This affected two (2) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94 and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as "modified independence" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They again denied having ever received complaints or allegations of neglect involving this resident. d) The faciltiy failed to acknowledge that complaints filed on behalf of Residents #94 and #96 contained allegations of abuse and/or neglect, failed to immediately report these allegations to State agencies as required, and failed to thoroughly investigate these allegations. . | 2014-04-01 | ||
| 11392 | NELLA'S INC. | 51A010 | 399 FERGUSON ROAD | ELKINS | WV | 26241 | 2010-03-17 | 165 | D | N9NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to support each resident's right to voice grievances and failed, after receiving a complaint or grievance, to actively seek a resolution and keep the resident or his or her representative appropriately apprised of the facility's progress toward resolution. This affected three (3) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94, #95, and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. A review of the facility's complaint policy, provided by the social worker on 03/16/10, revealed the following: "ALL COMPLAINTS RECEIVED BY THE FACILITY MUST BE DOCUMENTED IN THE COMPLAINT LOG, KEPT AT THE CHART DESK ON THE A-SIDE." "ALL COMPLAINTS AND SOLUTIONS SHOULD BE MAINTAINED IN A FILE FOR FUTURE REFERENCES, AFTER A COPY HAS BEEN SUBMITTED TO THE ADMINISTRATOR." b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #95 Review of Resident #95's closed record revealed an [AGE] year old male who was admitted to the facility on [DATE], and who was discharged to another nursing home on 03/01/10 at the request of his HCS, who was the DHHR case worker. Further review of the record revealed a nursing note, for the morning of 02/10/10, recording that the resident's daughter contacted the social worker to complain about not having been informed of the resident having been sent to the hospital emergency roiagnom on the previous day. The family learned about the transfer on 02/10/10 from the DHHR case worker who, according to the notes, had instructed the facility's social worker to keep the resident's family informed when he was sent to the hospital, even though they were not the resident's legal decision makers. Although there was documentation to reflect numerous phone calls made to DHHR regarding the resident's status, there was no evidence the family was informed when changes occurred in the resident's condition or treatment. At 5:00 p.m. on 02/10/10, the DON recorded in the resident's record that she had received a call from the WV State Police informing her the resident's family had complained that the resident had been sent to the hospital but the facility would not tell them where. During an interview with the social worker and the DON at 1:30 p.m. on 03/16/10, they stated they did not consider the above incident a complaint, because the family was not the resident's responsible person and had no right to complain. They stated that the only reason for the voluminous documentation in the chart was for "legal reasons". d) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as "modified independence" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter reported Resident #96 fell at the facility on 01/29/10, sustaining numerous bruises on her face, legs, hip, abdomen, and back and a laceration on her right calf; she was taken to the emergency room and returned to the facility. The daughter questioned facility staff about how the fall happened and was told it happened in the dining room, but she was never given any additional information. It was at this point the family member started making arrangements to care for her mother at home. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter reported that a motorized scooter was purchased for the resident's use, and the family was told the resident could use it after being taught how to safely do so by physical therapy. The therapist notified the family by phone the resident could not use the scooter, because he had been notified that she had run it into a wall. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. Record review found an incident / accident report, dated 01/29/10, which noted the resident had fallen while using her walker; documentation on the report confirmed injuries were sustained as a result of this fall. Documentation on the report also indicated the family was notified of the fall, but there was no mention on the report of the family having questioned the circumstances of the fall. Review of Resident #96's closed record found the only documentation about the scooter was a physical therapy note on 02/10/10, which recorded the resident was being evaluated for a scooter. There was no incident / accident report or other documentation about the resident running the scooter into a wall, and no one at the facility (including the physical therapist), when questioned by this surveyor, could remembered any incident involving the resident having done this. 4. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They also denied that anyone had ever complained about the resident not being allowed to use the scooter. They again denied having ever received complaints or allegations of neglect involving this resident. e) The facility failed to support each resident's right to voice grievances, by failing to register and respond to all complaints filed on behalf of Residents #94, #95, and #96 by their family members or legal representatives. . | 2014-04-01 | ||
| 11393 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 323 | G | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have "bruising each side of her nose" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was "slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)." - On 11/25/10 at 8:30 p.m., a report stated, "Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash." - On 11/27/10 at 5:00 p.m., another report stated, "CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted." No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., "CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..." - On 07/29/10 at 6:00 a.m., "Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct." - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), "Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..." Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: "Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms." The goal associated with this problem statement was for this resident to "wander safely and have no injuries r/t falls through review date." Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. - 7. Resident #24, when asked if he was bothered by wandering residents during an interviewed 12/06/10 at 12:15 p.m., stated that yes he was and that Resident #20 had wandered into his room the previous night, taken his soft drink, and dumped it into the sink. When asked what he did in response, he stated that he "took ahold of him (Resident #20)" then a nurse came in and told him he couldn't do that. When asked if a barrier-type stop sign had ever been offered to him to deter wanderers from entering his room, Resident #24 stated, "No." - 8. Following the interview with Resident #24, the facility was toured and observation found only two (2) barrier-type stop signs in use on two (2) resident rooms, but the devices were not attached in a manner that would deter a wanderer; in both cases, the banners were hanging on one (1) side of the doorway instead of being secured across the doorways as intended. On the second day of the investigation (12/07/10), observation found three (3) such barriers in place. The third barrier was noted to be across the entrance to Resident #24's room. When interviewed again on 12/07/10 at 11:00 a.m., Resident #24 stated he asked staff for the barrier after speaking with this surveyor the previous day. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his "head gashed open". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found " lying on floor with roll table over him." Notes stated, "Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall." - On 10/11/10 at 9:30 a.m., the resident was "found lying on fall mat in his room (sic) assisted back to bed." - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. "fell on R knee and R elbow." - On 10/14/10 at 10:15 a.m., "Resident exited facility through Activity Room Door. Brought back in without difficulty." - On 10/19/10, "Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor." - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., "Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor." - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the "grate" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. "Resident still had his support hose on." - On 11/15/10 at 10:05 p.m., "Heard resident yelling, found resident laying on the floor in resident's room." The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. "Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed." - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, "Not sure if (fall was) from bed or chair." The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, "Resident's bed alarm ringing and was on the floor skin tear to R (right) knee." - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. Observation, at 2:34 p.m. on 12/07/10, found Resident #20 lying on his bed. There was no body alarm present in the room, and the bed alarm was disconnected. This observation was confirmed by the DON, who stated, "It can't work if it's not connected." - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to psychotropic drug use and he had the potential for "adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care." Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a head laceration to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: "High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior." The goal related to this problem statement was: "Resident to remain safe, free from injury." Approaches to assist the resident in attaining this goal included: "Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed." The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for "no known reason" and was noted to have said, "I'm gonna give him one." The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 "punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye." - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others. | 2014-04-01 | ||
| 11394 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 280 | D | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to review / revise their care plans with new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Resident identifiers: #19, #20, and #36. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have "bruising each side of her nose" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was "slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)." - On 11/25/10 at 8:30 p.m., a report stated, "Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash." - On 11/27/10 at 5:00 p.m., another report stated, "CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted." No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., "CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..." - On 07/29/10 at 6:00 a.m., "Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct." - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), "Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..." Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: "Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms." The goal associated with this problem statement was for this resident to "wander safely and have no injuries r/t falls through review date." Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his "head gashed open". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found " lying on floor with roll table over him." Notes stated, "Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall." - On 10/11/10 at 9:30 a.m., the resident was "found lying on fall mat in his room (sic) assisted back to bed." - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. "fell on R knee and R elbow." - On 10/14/10 at 10:15 a.m., "Resident exited facility through Activity Room Door. Brought back in without difficulty." - On 10/19/10, "Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor." - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., "Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor." - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the "grate" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. "Resident still had his support hose on." - On 11/15/10 at 10:05 p.m., "Heard resident yelling, found resident laying on the floor in resident's room." The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. "Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed." - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, "Not sure if (fall was) from bed or chair." The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, "Resident's bed alarm ringing and was on the floor skin tear to R (right) knee." - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to [MEDICAL CONDITION] drug use and he had the potential for "adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care." Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a [MEDICAL CONDITION] to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: "High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior." The goal related to this problem statement was: "Resident to remain safe, free from injury." Approaches to assist the resident in attaining this goal included: "Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed." The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for "no known reason" and was noted to have said, "I'm gonna give him one." The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 "punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye." - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others. . | 2014-04-01 | ||
| 11395 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 281 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, staff interview, and review of the Criteria for Determining Scope of Practice for Licensed Nurses published by the State licensing boards for registered professional nurses and licensed practical nurses (LPNs), the facility failed to provide services that meet professional standards of quality, as evidenced by the facility allowing an unknown employee to obtain intravenous access through an improper access site. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report dated 07/28/10 revealed an unknown employee had obtained intravenous access through Resident #109's port-a-cath without a physician's orders [REDACTED]. Review of the nurses note revealed no documentation of the incident and no clarification of the physician's orders. Review of the physician's orders [REDACTED]." Another hand-written entry, with no date, stating access port-a-cath times three (3) weeks after the following order: "[MEDICATION NAME] HCl 1 gram Intravenous (IV) - Q12H Everyday, 0900 2100: 1 gram Q12 [MEDICAL CONDITION]." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 3:00 p.m., revealed the DON agreed that a port-a-cath should never be used as an intravenous access site without a physician's orders [REDACTED]. Review of the Criteria for Determining Scope of Practice for Licensed Nurses, revised in 2009, revealed a Scope of Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse. Review of the Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse revealed a guideline stating: "Is there a written order from a licensed Physician, Physician's Assistant, or Advanced Practice Nurse or is there a signed written protocol? If No, report / defer to qualified individual." Further review also revealed a guideline stating: "Would a reasonable and prudent nurse perform the act? If No, report / defer to qualified individual." . | 2014-03-01 | ||
| 11396 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 309 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. . | 2014-03-01 | ||
| 11397 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 441 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control policies / procedures, review of the daily census report, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, as evidenced by improper cohorting of a resident with Methicillin-resistant Staphylococcus aureus (MRSA) with a compromised resident. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #13. Facility census: 108. Findings include: a) Resident #13 Review of Resident #13's medical record revealed she had been cohorted in a room with Resident #82, who was positive for MRSA since 10/29/10. Review of the daily census report revealed Resident #13 was moved to another room on 11/01/10. Review of the physician's orders [REDACTED]. Resident #13 was receiving the following treatments: "Cleanse left lower leg with soap and water. Apply [MEDICATION NAME] cream, [MEDICATION NAME], and netting 2x per day on 7-3 and 11-7. Check placement QS. - NS, DS Everyday." and "Cleanse right lower leg with soap and water. Apply [MEDICATION NAME], and netting 1 time per day 7-3. Check placement QS. - DS Everyday." Review of the facility's infection control policies / procedures revealed a resident with MRSA "may be placed with a 'low risk' individual. Low risk means that the resident would not be clinically compromised. Definition of non-compromised resident is one who does not have surgical or other wound / open area." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 1:20 p.m., revealed he did not feel that Resident #13 was "low risk",and he further stated the proper protocol would have been to place Resident #82 on contact precautions, remove Resident #13 from that room, and contact the physician. | 2014-03-01 | ||
| 11398 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2010-11-23 | 333 | D | D3L711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents were free of significant medication errors, when a resident's [MEDICATION NAME] (an anticoagulant) was not administered in accordance with physician's orders [REDACTED]. This was found for one (1) of six (6) records reviewed. Resident identifier: #99. Facility census: 128. Findings include: a) Resident #99 The medical record of Resident #99, when reviewed on 11/22/10 at 2:00 p.m., revealed this [AGE] year old woman had resided in the facility since 07/24/09 and was receiving [MEDICATION NAME] therapy for [MEDICAL CONDITION]. ([MEDICATION NAME] dosage is regulated based upon laboratory testing results designed to measure the blood clotting time and blood clotting factor.) Resident #99 was ordered a dosage of [MEDICATION NAME] for 1.5 mg by mouth every other day, alternating with [MEDICATION NAME] 3.0 mg by mouth every other day on 09/01/10. She was found to be stable on this dosage until lab results, dated 10/25/10, were elevated. A new order was written on 10/27/10, for [MEDICATION NAME] 3.0 mg by mouth on Day 1, then 1.5 mg by mouth on Days 2 and 3 on a repeating cycle, thus lowering the overall dosage. Documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/01/10, the monthly recapitulation (recap) of physician's orders [REDACTED]. Consequently, the [MEDICATION NAME] orders on the November 2010 MAR indicated [REDACTED]. The physician had ordered on [DATE] (when the dosage was lowered) that a repeat lab test be conducted in two (2) weeks, because of the elevated results observed on the 10/25/10 test. When the lab results were obtained on 11/10/10, they were still elevated, and the error was apparently recognized. The dosage was subsequently changed back to conform with the physician's orders [REDACTED]. The MAR for November 2010 confirmed Resident #99 received [MEDICATION NAME] per the 10/27/10 order on 11/10/10 through 11/30/10. The record revealed Resident #99 received the wrong dosage of the [MEDICATION NAME] for nine (9) days, with the potential for increased bleeding. - Interview with the facility's director of nursing (DON - Employee #17, on 11/23/10 at 11:20 p.m., confirmed the dosage of [MEDICATION NAME] administered to Resident #99 was incorrect for the first nine (9) days of November 2010. She indicated she would conduct further investigation and return to continue the discussion. On 11/23/10 at 11:27 a.m., the DON returned with a medication error report that had been completed by the facility on 11/10/10, confirming the conclusion reached during the initial record review. The medication error report stated Resident #99 received the incorrect dose for "approx (sic) 9 days." In response to the question "Could the error have endangered the life or welfare of the patient?" was checked "yes". Under "Explain" was written: "Increased (arrow pointing up) bleeding risk." | 2014-03-01 | ||
| 11399 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 278 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. . | 2014-03-01 | ||
| 11400 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 241 | D | FRRZ11 | Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. . | 2014-03-01 | ||
| 11401 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 279 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote "I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day." During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) and the MDS coordinator revealed this resident did not communicate well and would not be able to verbalize in this manner, and this statement and care plan did not accurately describe the resident's pain was not accurate. c) Resident #28 A review of the resident's medical record revealed [REDACTED]. A review of the resident's care plan revealed the hospice care plan was not integrated with the facility's care plan for the resident. . | 2014-03-01 | ||
| 11402 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 309 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. . | 2014-03-01 | ||
| 11403 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 441 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. . | 2014-03-01 | ||
| 11404 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 225 | D | FRRZ11 | Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, "he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks." The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, "Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided." The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. . | 2014-03-01 | ||
| 11405 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 279 | E | QWDA11 | . Based on observation, record review, and staff interview, the facility did not develop care plans for six (6) of seven sampled residents to provide justification for the residents to sit in the facility hallways in front of the nursing station to eat their meals. Resident identifiers: #19, #6, #26, #46, #45, and #44. Facility census: 75. Findings include: a) Residents #19, #6, #26, #46, #45, and #44 Observations, on 11/01/10 beginning at 12:15 p.m., found the above-identified six (6) residents sitting in front of the nursing stations in the hallways eating their lunch. Some of the residents were able to eat without assistance, and others were being fed by the staff. Four (4) residents (#6, #26, #46, and #45) were observed on the South hall, and two (2) residents (#19 and #44) were observed on the North hall. An interview with the director of nursing (DON), on 11/01/10 at 12:15 p.m., revealed the residents wanted to eat in the hallway in front of each nursing station. She further stated that some of the residents were unable to make the decision to eat in the hallway and the legal representative requested that the resident eat in the hallway in front of the nursing station. The DON also stated all of these residents had a care plan identifying the reason for each resident eating meals in this location. A review of the care plans these residents found no mention of eating their meals in the hallways. . | 2014-03-01 | ||
| 11406 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 309 | D | QWDA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of seven (7) sampled residents did not receive the influenza vaccine in accordance with the legal representative's wish to decline the vaccine due to an allergy. Resident identifier: #19. Facility census: 75. Findings include: a) Resident #19 Record review revealed a facility consent form titled "Vaccine Administration Authorization", upon which was recorded either acceptance or refusal to receiving the influenza vaccine, indicated that Resident #19's legal representative declined administration of the influenza vaccine, because the resident was allergic to it. On 10/21/10 at approximately 6:30 a.m., a nurse administered the influenza vaccine to the resident contrary to the wishes of the legal representative. At 8:00 a.m. on 10/21/10, Resident #19 became unconscious and was transferred to the hospital and admitted . Review of hospital records for Resident #19 revealed, "[AGE] year old female nursing home resident presented to the hospital after having two [MEDICAL CONDITION]. Patient had received [MEDICATION NAME] at the nursing home after getting the flu vaccine which she is allergic to. Patient had recently been taken off [MEDICATION NAME] which she was on for a number of years for agitation. Two weeks prior to having [MEDICAL CONDITION], [MEDICATION NAME] was discontinued abruptly and she was started on [MEDICATION NAME]. Patient was admitted and we restarted [MEDICATION NAME]." The hospital obtained an electrocardiogram (EKG), serial cardiac enzymes, CT of the brain, electroencephalogram (EEG), a chest X-ray, and blood work, and all results were within normal limits. An interview with the assistant director of nursing (ADON - Employee #32), on 11/01/10 at 1:30 p.m., revealed she was called to Resident #19's room after the influenza vaccine was administered to the resident by mistake at approximately 6:30 a.m. on 10/21/10. She immediately told the nurse to call the physician to obtain an order for [REDACTED]. The family of the resident had told her the resident was not allergic to eggs but was allergic to a preservative that was in the influenza vaccine and that she could not have the vaccine. The ADON also described the procedure the facility completed before administering the influenza vaccine, which involved gathering all consent forms for the vaccine and reviewing any allergies [REDACTED]. On the morning of 10/21/10, the nurse and the staff development coordinator had assembled the consent forms. The nurse had not reviewed the physician orders [REDACTED]. An interview with the director of nursing (DON), on 11/01/10 at 2:00 p.m., revealed, the nurse who administered the influenza vaccine to Resident #19 was no longer working at the facility. She further stated the nurse had not looked at the authorization form that indicated the resident was not to receive the vaccine and the nurse did not review the resident's physician orders [REDACTED]. An interview with the current staff development coordinator (Employee # 82), on 11/02/10 at 10:30 a.m., revealed he and another nurse had gathered vaccine administration authorization forms and the nurse was going to give the vaccine to the residents. The former staff development had asked them if they had reviewed the physician orders [REDACTED]. The nurse told him she had not looked at the physician orders [REDACTED]. He further stated the nurse apparently had not looked at the authorization form, because the resident received the vaccine and the authorization form indicated a refusal for the vaccine. A telephone interview with the facility's medical director, on 11/02/10 at 10:30 a.m., revealed he was not certain why the resident had the two (2) [MEDICAL CONDITION] after the flu vaccine was administered. The physician further reported he had never seen an influenza vaccine cause [MEDICAL CONDITION]. | 2014-03-01 | ||
| 11407 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-11-11 | 244 | E | VERC11 | . Based on review of resident council meeting minutes and staff interview, the facility failed to act upon a grievance made during a resident council meeting. On 09/27/10, residents expressed concerns regarding call lights not being answered during the midnight shift on Unit 4. This concern was not addressed by facility personnel. This practice had the potential to affect twenty-six (26) of twenty-six (26) residents who resided on Unit 4. Facility census: 107. Findings include: a) Review of the facility's 09/27/10 resident council meeting minutes, on 11/11/10, revealed residents expressed a concern regarding call lights not being answered on the midnight shift on Unit 4. Further review of the minutes revealed no evidence this concern had been acted upon by facility personnel. On 11/11/10 at 1:00 p.m., the administrator (Employee #16) was asked to provide evidence this issue had been addressed by the facility. At 1:10 p.m., Employee #16 reported the concern had not been acted upon as required. | 2014-03-01 | ||
| 11408 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 157 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused"). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Provide nebulizer treatments as ordered." Review of the facility's policy titled "Notification of Refused or Held Medications / Treatments" (policy #F-005, dated 10/15/05) found under the heading procedure: "A. When a medication / treatment cannot be administered as ordered, the prescriber must be notified." In an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) confirmed that nursing staff should have notified the physician that this resident was refusing her inhalation treatments at times. . | 2014-03-01 | ||
| 11409 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 225 | D | 50T311 | . Based on review of information from a criminal background check, staff interview, and review of a 2004 newsletter issued by the Office of Health Facility Licensure and Certification (OHFLAC) to all Medicare / Medicaid nursing facilities, the facility failed to ensure a West Virginia State Police background check was completed prior to hire for one (1) of one (1) background checks reviewed. Employee #123, a certified nurse practitioner (CNP), had been employed at this facility since May 2010, and no criminal background check by the West Virginia State Police had been completed as required by OHFLAC. Employee identifier: #123. Facility census: 118. Findings include: a) Employee #123 During a complaint investigation conducted at the facility between 11/08/10 and 11/11/10, it was discovered the facility had employed Employee #123 as a CNP since May 2010. Review of Employee #123's personnel record revealed the pre-employment screening conducted on this individual did not include a criminal background check by the West Virginia State Police in an effort to uncover a personal history of criminal convictions that may indicate this individual was unsuited for employment in a nursing facility. In an interview on the afternoon of 11/09/10, the facility's administrator (Employee #53) confirmed a criminal background check had not been conducted through the West Virginia State Police prior to hiring Employee #123. Review of a newsletter (dated November 2004), which had been distributed by OHFLAC to all Medicare / Medicaid certified nursing facilities in West Virginia, revealed the following directive: "... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. Individuals for whom criminal background investigations have been initiated may begin work at the facilities pending satisfactory outcomes of the checks. ..." . | 2014-03-01 | ||
| 11410 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 281 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of May 2002) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. . | 2014-03-01 | ||
| 11411 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 309 | G | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded "OK". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and "looked at the resident, then turned around and left the room", and one (1) of the nurses stated, "I'm sending her out of here. I'm leaving at 7:00." There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and "eyes not reactive to light accommodation". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of [DATE]) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was "Respiratory Arrest"; other signs and symptoms included "Decreased LOC". In the narrative section on page 1 of 6 was recorded, "Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..." Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, "Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending." Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of ",[DATE]") revealed the following: "Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident." "Procedure - Action Steps "1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) "2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. "3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. "4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. "5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) "6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. "7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions." According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as "nursing notes") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of "Change in Condition" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, "to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER." The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being "frail and alert oriented x 2" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: "blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed." At the end of this progress note was written: "Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable." - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: "[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting." and "IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)." The second sheet of orders contained one (1) set of entries as follows: "IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2." - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were "too accustomed to picking up the phone and calling EMS". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she "went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS." This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res | 2014-03-01 | ||
| 11412 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 328 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for [REDACTED].) - 3. Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of May 2002) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. (See also citation at F281.) - 4. A CNP progress note dated 10/13/10 (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated 10/14/10 (and electronically signed electronically at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is 135/738 (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on October 14, 2010 and end on October 18, 2010. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on October 14, 2010 and end on October 20, 2010." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on 10/14/10, with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on 10/14/10 (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated 10/14/10 was identified as having been an amendment to the earlier progress note at 1:57 p.m. on 10/14/10. This amendment, which was electronically signed by the CNP at 10:44 a.m. on 10/15/10, contained the exact same information as found on the earlier note for 10/14/10 under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." . | 2014-03-01 | ||
| 11413 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 514 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." - According to the AHIMA LTC documentation guidelines: "5.2.15. Condition Changes "Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical." The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #119's health status in accordance with professional standards of practice. -- 2. Review of the closed medical record for Resident #119, who was transferred to the hospital on the evening of [DATE] and subsequently expired, found a nursing note, dated [DATE] at 3:27 p.m., which contained six (6) separate late entries describing events said to have occurred one (1) week earlier between 1:00 p.m. and 5:00 p.m. on [DATE]. - According to the "as-worked" nursing schedule provided at 3:30 p.m. on [DATE] by the director of nursing (DON - Employee #81), the author of the late entries recorded on [DATE] (a licensed practical nurse (LPN - Employee #19)) worked from 7:00 a.m. to 7:30 p.m. on [DATE]. During the 7:00 a.m. to 7:30 p.m. shift on [DATE], Employee #19 recorded entries at 4:-0 (exact time not legible), 5:25 p.m., 7:00 p.m., and 7:22 p.m.; Employee #19 worked in the facility again from 7:00 a.m. to 7:30 p.m. on [DATE], and from 7:00 a.m. to 7:30 p.m. on [DATE] and would have been available to record these late entries more timely than she did. - According to the AHIMA LTC documentation guidelines: "5.3.2.1. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ... "When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes." The late entries recorded by Employee #19 were not entered into Resident #119's record as soon as possible (which would have been during the 7:00 a.m. to 7:30 p.m. shift on [DATE]. Instead, they were recorded seven (7) days after the resident expired. This significant delay in recording the late entries calls into question the reliability of their contents. -- 3. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on [DATE] following a prolonged hospital stay beginning on [DATE] during which she received treatment for acute [MEDICAL CONDITION] (ARF). Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. - Review of the [DATE] MAR found, for her only day present in the facility in September ([DATE]), she had an order to receive [MEDICATION NAME] inhalation treatments every six (6) hours (at regular intervals four (4) times a day). Review of the [DATE] MAR indicated [REDACTED]. - In an interview at 3:30 p.m. on [DATE], the DON reported the resident was to have received the inhalation treatments every four (4) hours and the physician orders [REDACTED]. - Review of a progress note dictated by the certified nurse practitioner (CNP), dated [DATE] and electronically signed at 2:39 p.m., found an entry stating to continue to nebulizer treatment for two (2) weeks and re-evaluate. Review of the physician orders [REDACTED]." Further review of physician orders [REDACTED]. Based on the information available in the resident's closed record, it is unclear when one (1) or more transcription errors may have occurred - when the CNP recorded the handwritten order to continue the [MEDICATION NAME] treatments on [DATE] (at a frequency different from what was specified in the resident's hospital discharge order), or when the order was carried over from the [DATE] MAR indicated [REDACTED] | 2014-03-01 | ||
| 11414 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2010-11-18 | 311 | D | 0ZJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used. | 2014-03-01 | ||
| 11415 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 309 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who was no longer affiliated with the facility) and made an appointment to have her evaluated. - Record review revealed a nursing note, dated 04/28/10 at 5:30 p.m., which stated, "... Resident C/O (complained of) sore tongue (sic) slightly red / inflamed. (Name of attending physician) notified (sic) new order [MEDICATION NAME] 10 mg x 2 weeks - resident notified." On 04/29/10 at 1:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont(inued) for mouth soreness. No complaints at this time." On 04/29/10 at 7:40 a.m., a nurse wrote, "... [MEDICATION NAME] to begin this AM (morning) for sore mouth, tongue slightly red and irritated. ..." On 04/29/10 at 4:00 p.m., a nurse wrote, "... [MEDICATION NAME] cont /s (without) adverse effects noted r/t (related to) sore touth (sic), tongue - slightly red / irritated - denies any further C/O (complaints). ..." On 04/30/10 at 8:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont /c (with) no adverse effects noted for sore mouth, tongue slightly red, irritated. Denies any C/O this AM. ..." On 04/30/10 at 11:30 a.m., a nurse wrote, "Dtr (daughter) made appt (appointment) today /c (name of outside physician) at 1:30 p - follow-up (sic). Facility to take." On 04/30/10 at 3:00 p.m., a nurse wrote, "Returned back from (name of outside physician). Dx (diagnosis): glossitis, mouth ulcers, possible candidias (sic). New orders OK per (name of facility's physician): (1) [MEDICATION NAME] xylocane (sic) 1 tablespoon swish, gargle, and swallow QID (four times a day) x 10 days. (2) [MEDICATION NAME] 150 mg qday (sic) (every day) x 3 days. (3) 2 cc B12 IM (intramuscular injection) in AM. (4) 80 mg [MEDICATION NAME] IM x 1. (5) [MEDICATION NAME] oral susp(ension) 1 tsp QID PO (by mouth) swish, gargle, and swallow x 10 days. Dtr notified. Cont to monitor." This entry was followed by an addendum, dated 04/30/10, noting the discontinuation of the [MEDICATION NAME]. - The nursing entries from 04/28/10 until 04/30/10 only addressed the resident's irritated tongue and did not contain evidence of an assessment of the resident's oral cavity as a whole; there was no mention of the presence of mouth ulcers which had been identified by the outside physician on the afternoon of 04/30/10. - In an interview on 11/16/10 at 8:45 a.m., the director of nursing (DON - Employee #88) reported the nurses had assessed the resident's mouth and only found that the resident had an irritated tongue. A nurse called the facility's physician and told him about the irritated tongue, and he ordered [MEDICATION NAME]. The DON provided, as evidence of assessment of the resident's oral cavity, a nursing assessment form (which include an oral / nutritional assessment) dated 02/27/10. However, this nursing assessment was completed two (2) month before the resident was diagnosed by the outside physician as having a glossitis, mouth ulcers, and possible candidiasis, for which he ordered treatment with five (5) medications. The DON further stated the facility's physician was in and visited the resident on 04/26/10, and there was no evidence the resident had complained about a sore mouth at that time. - A review of the physician's progress notes found an entry, dated 04/26/10, which did not indicate the resident had complained of a sore mouth. This physician visit, however, occurred two (2) days prior to the resident's first complaint of a sore mouth on 04/28/10. - A review of the monthly summary completed, by a licensed nurse on 04/05/10, revealed a section titled "16. Oral Hygiene". Within this section was "Condition of Mouth" followed by a space where a description of findings could be recorded; this space was left blank. - Review of nursing notes entered in the medical record after the resident returned from her outpatient physician visit on the afternoon of 04/30/10 with orders to treat found references to the resident's complaints of mouth pain or discomfort in entries made at 4:00 p.m. on 05/01/10, at 6:20 a.m. on 05/02/10, at 9:50 a.m. on 05/02/10, and at 4:00 p.m. on 05/02/10. However, there were no entries describing the physical condition of the resident's oral cavity until 10:00 p.m. on 05/03/10, when a nurse wrote: "... Cont to have observable mouth ulcerations /c C/O discomfort..." - Resident #153's daughter, after hearing complaints of oral pain and soreness from the resident and after hearing a report by her brother of the presence of sores in her mother's mouth, reported having asked facility staff to have the attending physician evaluate her. The facility failed to provide a full assessment, either by a registered nurse or the physician, of the resident's oral cavity after the resident complained of pain and soreness to her mouth. The resident's daughter was required to intervene and schedule an appointment with an outside physician in order to obtain appropriate treatment for [REDACTED]. -- b) Resident #73 During the observation of the passing of medications at 9:00 a.m. on 11/10/10, the licensed practical nurse (LPN - Employee #13) failed to administer [MEDICATION NAME] 25 mg which was ordered to be given at that time to Resident #73. The nurse surveyor compared the list of medications verbally told to her by the LPN during the medication pass (and observed being given to the resident) with the physician's orders [REDACTED]. Employee #13 continued on with her medication pass to the remaining residents on the B hall. During an interview with Employee #13 at 9:50 a.m. on 11/10/10, after she had completed the pass, she acknowledged she had not administered the [MEDICATION NAME]. She reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A comparison of the medications in the medication cart labeled for use by Resident #73 with the resident's MAR indicated [REDACTED] . | 2014-03-01 | ||
| 11416 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 315 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of "very cloudy and dark" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with the presence of an indwelling urinary catheter, and she had NOT been diagnosed with [REDACTED]. -- According to her care plan dated [DATE] through [DATE], the interdisciplinary team identified the following problem: "Risk for infection R/T (related to) indwelling foley (sic) cath (sic) and hx (history) of uti (sic)." The goal associated with this problem statement was: "Resident will exhibit no s/sx (signs / symptoms) of UTI thru next review aeb (as evidenced by) afebrile, no change in sedimentation of urine." The interventions intended to assistant the resident in achieving this goal included: "#16F foley (sic) with 30cc balloon per orders, Change Q (every) 4 weeks and prn (as needed). change (sic) urinary drainage bag Q 4 weeks and prn. Foley cath care Q shift. Provide incontinence cares (sic) frequently as able ensuring proper peri care due to increased risk of ecoli (sic) infection. Encourage and assist with fluids with and between meals for preventative measures. Monitor for s/sx of UTI such as hematuria (blood in urine), dysuria (painful urination), pyuria (pus in urine), abdominal pain, temp (sic), increasd (sic) confusion, etc. Notify MD as needed. hx (sic) of vre ([MEDICATION NAME]-resistant [MEDICATION NAME]). Monitor for s/s of uti (sic) during periods of increased blood sugars. Notify md (sic) of findings." -- A nursing note, dated [DATE] at 12:30 a.m., revealed, "Temp (temperature) 100.2 (symbol for 'oral') ... Urine very cloudy and dark. New order (sic) UA (urinalysis) & C&S (culture and sensitivity) this AM (morning) ...." A nursing note, dated [DATE] at 11:15 p.m., stated, "Labs returned. Abnormal UA - pH 9.0, Protein 75, Blood 250, Leukocyte Est 500 preliminary (sic) awaiting final." (The normal ranges for these labs are: pH = 4XXX,[DATE].0, Protein = negative (0), Blood = negative (0), and Leukocyte Est = negative (0).) The next consecutive entry in the nursing notes, dated [DATE] at 12:20 a.m., stated, "Temp 97.6 (Ax) (axillary). Foley catheter draining cloudy dark yellow." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, " ... yells / moans @ (at) times (sic) complaints generally nonspecific and cease /c (with) conversation. T (temperature) 99.0 (symbol for 'oral') awaiting final C&S of UA. foley (sic) cath patent (sic) draining tea colored urine. denies (sic) abd(ominal) pain upon palpation. C/O (complains of) bladder feeling full (sic) abd small & soft. ... fluids (sic) encouraged by staff as well as ice chips ... will continue to monitor." The next consecutive entry, dated [DATE] at 4:00 p.m., stated, "Temp 98.6 (Ax). ... Yells / moans out occas (occasionally) /c C/O mouth pain. ... ice chips & fluids encouraged. foley (sic) cath patent draining dark tea colored urine - slightly blood tinged. Awaiting C&S of UA. ..." The next three (3) consecutive entries in the nursing notes (dated [DATE] at 6:20 a.m., [DATE] at 9:50 a.m., and [DATE] at 4:00 p.m.) contained no mention of the status or characteristics of the resident's urinary output. The next entry, dated [DATE] at 2:10 a.m., stated, " ... Indwelling foley (sic) drng (draining) small - mod amts of dk sl amber urine. ..." The next consecutive entry in the nursing notes, dated [DATE] at 10:00 a.m., stated, "Temp 99.6 (Ax). Lethargic. C/O not feeling well (sic) not wanting to be bothered." An addendum following this entry stated, "10 am. Received napoxen (sic) ([MEDICATION NAME] - a non-steroidal anti-[MEDICAL CONDITION] drug) @ 7:45 a.m. Will cont to monitor for S/Sx fever; infection." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, "Up to BSC (bedside commode) (sic) became very weak, pale. Put back to bed. BP (blood pressure) ,[DATE]. P (pulse) 84. Skin cool (sic) clammy. After stimulation BP ,[DATE] P 82. Had expelled hard BM (bowel movement) prior to episode." The next consecutive entry, dated [DATE] at 11:30 a.m., stated, "Yelling (sic) insisting to be back up on BSC. ..." This was followed by an entry by the same author with the same date and time, noting that a dose of [MEDICATION NAME] was withheld related to a possible adverse effect. The next consecutive entry, dated [DATE] at 10:00 p.m., stated, " ... also C/O feeling very weak - orders rec (received) for lab wk (work) in AM (morning). Res (resident) made aware." The next consecutive entry, dated [DATE] at 4:00 a.m., stated, "Resting quietly in bed - awakens easily (sic) appears sl (slightly) listless. ... Ate 0% of meals [DATE] /c only (approx) 300 ml of fluids /c meals ..." The next consecutive entry, dated [DATE] at 5:00 a.m., noted the arrival of the vendor laboratory service to collect specimens for blood work. The next consecutive entry, dated [DATE] at 10:00 a.m., stated, "Lethargic. BS (blood sugar) elevated. BP low. Consulted Dr. (name of attending physician) /c exam. New order. Novalog ,[DATE] 10 units bid (twice daily). IV (intravenous fluids) 0.45% NaCl @ 100 cc/hr x 2 hours then 80 cc/hr. Transfer to (name of hospital) ER for eval." The next four (4) entries in the nursing notes recorded the successful insertion of the IV, notification of the resident's change in condition and transfer to the resident's legal representative, transfer of the resident to the hospital, and mailing of the notice of transfer and bedhold policy to the resident's legal representative. -- The above nursing notes recorded evidence of the resident exhibiting signs and symptoms of a UTI beginning on [DATE] (e.g., dark, cloudy urine; blood in urine; low grade temperature; lethargy). These signs and symptoms continued without treatment or physician intervention from [DATE] until [DATE], when the resident was transferred to the hospital. -- Review of a lab specimen inquiry dated [DATE] with a run time of 1146 (11:46 a.m.) revealed the following abnormal results of the blood work collected in the early morning hours of [DATE]: - Glucose - 354 (normal range ,[DATE]) - Blood urea nitrogen (BUN) - 194 (normal range ,[DATE]) Below this lab value on the report was typed, "Tried to notify Sunbrige (sic) of results - could not get pick-up on floor. Notified (name) (front desk) that I would be faxing results to floor. ..." - Creatinine - 5.1 (normal range 0XXX,[DATE].3) - B/C (BUN / Creatinine) Ratio - 38 (normal range ,[DATE]) - Potassium - 5.1 (normal range 3XXX,[DATE].5) -- Lab results after Resident #153 arrived at the hospital revealed the following: - Urine specimen collected on [DATE] (with results dated [DATE]) - the appearance was noted to be "turbid (cloudy) specimen red" with "large" amount of blood, equal to or greater than 300 mg/dl of protein in the urine, with a quantity of red blood cells in the urine "too numerous to count" and "loaded" with bacteria. - Blood specimen collected on [DATE] (with results dated [DATE]) - cultured positive for [DIAGNOSES REDACTED] pneumoniae and Streptococcus mitis group. The resident was septic and subsequently expired at the hospital on [DATE]. -- An interview with the director of nursing (DON - Employee #88), on [DATE] at 8:45 a.m., revealed the resident's attending physician would always wait until the final lab report was received to determine what antibiotic to order. She further stated the physician would treat if a resident were symptomatic, but according to the DON, Resident #153 only had an elevated temperature on [DATE] and was not symptomatic of a UTI. -- Resident #153 was exhibiting signs and symptoms of a UTI beginning on [DATE] and continuing to [DATE], when the resident was transferred to the hospital. There was no evidence to reflect staff notified the attending physician of the resident's dark, cloudy urine, the presence of blood in the resident's urine, the resident's moaning and yelling, her lethargy, and/or of the overall change in the resident's condition prior to [DATE]. . | 2014-03-01 | ||
| 11417 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 323 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: "Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage." The goal associated with this problem statement, with a target date of 08/18/10, was: "Will have no injury r/t falls thru next review." Interventions to achieve this goal included: "up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders." Review of her physician orders [REDACTED]." -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, "Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..." -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. A hospital operation summary, dated 08/19/10, stated, "The patient is a [AGE] year-old female who is known to me. Approximately a year ago, she sustained an intertrochanteric hip fracture while getting out of bed. ... She was admitted to an outside hospital and found to have a subtrochanteric femur fracture as above. She is extremely and morbidly obese. She does not really ambulate and has not ambulated for some time because of this. ..." -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." In a statement dated 08/15/10 at "12:15 about" (per the author of the statement), Employee #22 (a nursing assistant) wrote: "I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)." In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: "CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived." In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: "Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval." In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: "On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..." There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. (See also citation at F225.) -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, "The resident sustained [REDACTED]." -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resides in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She also stated, "I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling." -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, "The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor." -- A review of the "Owner's Operating and Maintenance" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the "sit-to-stand lift") revealed a "Safety Summary" on pages 4 and 5, which included the following in a box labeled "Warning": "DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. "Individuals that use the Standing Sling (Model R130) MUST be able to support the majority of their own weight, otherwise injury can occur. ..." In the section titled "Transferring From" on page 10, under the heading "Lifting the Patient (Figure 1)" were the following instruction to be performed before raising a resident above the surface being transferred from: "F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place." In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the "maximum open position") during the transfer of Resident #54, contrary to the manufacturer's instructions. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, "When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand." She further stated, "We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position." Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. . | 2014-03-01 | ||
| 11418 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 520 | E | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility census: 98. Findings include: a) Review of facility abuse / neglect self-reporting to State officials, on 11/11/10 at 9:30 a.m., revealed an incident that took place on 08/15/10 and was reported to the Office of Health Facility Licensure and Certification (OHFLAC, the State survey and certification agency) as an "unusual occurrence". Resident #54 sustained a fracture during an attempted transfer using a sit-to-stand lift. Documentation on the "Immediate Fax Reporting of Allegations" form, in the section headed "Brief description of the incident", stated: "Called to resident's room by staff. Resident holding on to bar of sit to stand (sic) with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor and squad called to take resident to ER (emergency room ) for eval." This form was signed by a registered nurse (RN - Employee #135). - The "Five-day Follow-up" form was completed on 08/18/10 by the facility's social worker (Employee #142). Documentation in the section headed "Outcome / Results of Investigation" stated: "Unusual occurrence - resident slid during attempted transfer. No indication that maltreatment occurred. Resident stated that she let go of handle bar of lift (sit to stand)." There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. - Two (2) written statements were included with the facility's reports from the nursing assistants who had been attempting the transfer. In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." - Review of all documentation associated with the facility's internal investigation found it was unclear how Resident #54 ended up on the floor. Employee #92 stated, "She then let go with the other hand and slid down to the floor." The description by the RN (Employee #135) stated, "Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor ... " There was no evidence of any investigation into statements by staff members of problems with using the sit-to-stand lift when transferring residents into and out of an electric bed, which apparently contributed to the resident's fall. -- b) A review of facility incident / accident reports, on 11/15/10 at 10:30 a.m., revealed an incident report for Resident #54 categorized as a fall, which documented the incident of 08/15/10 at 12:45 p.m. Documentation in the section headed "Describe the circumstances of the event and what actions, if any have been taken currently" stated, "Called to resident's room by staff. Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident was lowered to floor. Unable to move by staff and and squad was called to assist resident. 4 squad members and 2 RN, 1 LPN, 2 CNA (certified nursing assistants) assisted resident on back board and stretcher, support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated 'I am not in w/c (wheelchair) right.' Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor, unable to obtain VS (vital signs) D/T (due to) positioning." Documentation in the section headed "Recommendations to prevent further falls" stated: "Use mechanical lift for transfers." A hand written statement was attached to the report, composed by an RN (#111) and dated 08/16/10. It stated: "(Name of Employee #92), (name of Employee #134), and (name of Employee #81) were re-educated on the sit to stand lift following the (name of Resident #54) fall (sic) RMS (Risk Management System) # 1." There was no apparent investigation of the problem of using a sit-to-stand lift in conjunction with an electric bed. There was no reason given why it was recommended that a mechanical lift should be used with Resident #54 after the fall, instead of the sit-to-stand lift. There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. There was no explanation as to why it was necessary to provide re-education to only these three (3) employees (if nothing had been done improperly); if any re-education were felt to be warranted, there was no explanation as to why this re-education was not then provided to all staff that might use the sit-to-stand lift. -- c) Record review revealed Resident #54 was a [AGE] year old female who was 5' 1" tall and weighed between 280# and 301# during her residency in this facility; at the time of this survey event, Resident #54 resided in another facility. Resident #54 was interviewed via telephone at 9:55 a.m. on 11/16/10. She was asked about the incident of 08/15/10, which she said she recalled clearly. She stated that, when she was being moved in the lift, the lift tipped or lurched, causing her "to go over". She also reported her belief that the lift was broken at the time is was being used. -- d) During an interview with the director of nursing (DON - Employee #88) on 11/16/10 at 11:00 a.m., she stated there were some beds in the facility with which the sit-to-stand lift could not be used. She said the sit-to-stand lift could not be used with the electric beds, because the legs of the lift could not be fully opened when they were under the bed. She demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. -- e) The manufacturer's operating manual for the sit-to-stand lift was reviewed at 10:00 a.m. on 11/16/10. In the section headed "Lifting the patient", was Step F, which stated: "Make sure the legs are in the maximum open position and the shifter handle is locked in place." -- f) An interview was conducted, on 11/16/10 at 10:29 a.m., with the two (2) nursing assistants involved in the above-referenced event (Employees #92 and #134). They both stated that the legs of the sit-to-stand lift were not in the open position when they lifted Resident #54 from the bed and attempted to transfer her to the wheelchair and back. -- g) The facility's administrator (Employee #28), when interviewed on 11/15/10 at 2:30 p.m., was asked if the facility's QAA committee had topics that were always placed on the agenda for discussion by the committee members. He related there were items looked at in every meeting, which included past survey results, customer base, incidents / accidents, abuse / neglect reporting, medication errors, and department-specific topics related to their operations. Discrepancies found by the surveyor during an investigation into the events of 08/15/10, which included a review of written statements obtained by the facility from individual staff members, information obtained by the surveyor through interviews with staff members and a telephone interview with Resident #54, and a review of facility documentation, identified concerns related to the use by staff of the sit-to-stand lift during Resident #54's transfer resulting in a [MEDICAL CONDITION]. These discrepancies were discussed with the administrator, who was asked to provide to the surveyor any additional documentation not previously produced, to demonstrate the circumstances of Resident #54's transfer and fall were reviewed by facility management and/or the QAA committee and steps were taken to ensure no other residents were injured in the future during the use of the sit-to-stand lift. He voiced understanding and stated he had spoken with Resident #54 following the events of 08/15/10, and that she had not said anything to him about the lift tipping or lurching. He stated he had notes of this conversation. He subsequently provided: (1) a "Customer First Ambassador Rounds Worksheet", which he stated was the discussion with the resident when she returned from the hospital; (2) the facility's incident report of 08/15/10; and (3) a policy entitled "Resident / Patient Lifting / Transfer". - Upon review of Resident #54's "Customer First Ambassador Rounds Worksheet", this form consisted of observations and interviews conducted by the social worker (Employee #142) on 08/25/10, 08/26/10, 08/27/10, 09/13/10, 09/15/10, and 09/17/10. The interview questions were general satisfaction items, such as "Was the food appetizing in taste?", "Has the housekeeping staff kept you room to your satisfaction?", "Has the staff been taking good care of you?" The observations were also general in nature, covering areas such as hygiene and grooming, environment, and water pitchers. There was nothing found that addressed the incident of 08/15/10. - Review of the facility incident report provided by the administrator found that additional pages were attached, to include a cover sheet containing the signatures of the administrator and the DON, indicating they had reviewed the investigation of the incident. - Review of the facility's "Resident / Patient Lifting / Transfer" policy found it covered all aspects of lifting and transfer. The only specific mention of the sit-to-stand lift was under Section 4 for "Equipment", which stated: "Sit to-Stand Lifts - designed to assist the caregiver in standing a resident / patient up, without the need for any manual lifting. The resident / patient only needs minimal weight bearing ability to be transferred easily from bed to toilet or chair." There were no specific policies or procedures presented regarding appropriate use and safe operation of the sit-to-stand lift. There was no documented training or education provided to address whether the sit-to-stand lift should not be used with some beds (e.g., electric) or that the legs of the lift must be fully opened before lifting a resident. | 2014-03-01 | ||
| 11419 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 225 | D | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to conduct a thorough investigation, and make a report to the Nurse Aide Registry of two (2) nursing assistants, of neglect involving one (1) of eighteen (18) sampled residents who was injured during an unsafe transfer. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The facility's internal investigation into this fall was not thorough as evidenced by a failure to conduct an interview with the affected resident, who was alert and oriented and available for interview upon her return from the hospital to the facility; when interviewed by a surveyor, the resident related information markedly different from what had been reported by staff involved in the incident. The facility also failed to identify during its investigation that the sit-to-stand lift was not used in accordance with the manufacturer's instructions. The two (2) nursing assistants who were involved in the transfer failed to ensure the legs of the sit-to-stand lift were in the maximum open position for stability prior to attempting to transfer the resident. The facility did not identify this as neglect and/or report the individuals involved to the appropriate State agencies as required. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: "Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage." The goal associated with this problem statement, with a target date of 08/18/10, was: "Will have no injury r/t falls thru next review." Interventions to achieve this goal included: "up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders." Review of her physician orders [REDACTED]." -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, "Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..." -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." In a statement dated 08/15/10 at "12:15 about" (per the author of the statement), Employee #22 (a nursing assistant) wrote: "I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)." In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: "CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived." In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: "Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval." In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: "On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..." There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, "The resident sustained [REDACTED]." -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. He believed the staff involved was not negligent during the transfer, and he verified the two (2) nursing assistants were not reported to the Nurse Aide Registry. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resided in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She stated, "I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling." -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, "The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor." -- A review of the "Owner's Operating and Maintenance" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the "sit-to-stand lift") revealed, in the section titled "Transferring From" on page 10, under the heading "Lifting the Patient (Figure 1)", the following instruction to be performed before raising a resident above the surface being transferred from: "F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place." In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the "maximum open position") during the transfer of Resident #54. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, "When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand." She further stated, "We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position." Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. . | 2014-03-01 | ||
| 11420 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 242 | E | U2Q611 | . Based on staff interview and record review, the facility failed to identify and communicate to direct caregivers the residents' preferences with respect to what time of day they were to receive showers. This was evident for at least seventeen (17) of twenty-two (22) residents who routinely received showers during the night shift. Resident identifiers: #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Facility census: 150. Findings include: a) Residents #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Interviews with nursing staff working night shift on 10/24/10 and 10/25/10 revealed residents were being given showers and baths during this shift. A review of shower documentation sheets revealed residents were scheduled and listed as having been given a shower or bath at various times throughout the night shift. Staff stated, in confidential interviews, they showered or bathed anywhere from one (1) to three (3) residents this shift each day except Sunday. There was no evidence, via record review, to reflect the facility staff made efforts to ascertain whether the practice of bathing during the hours of night shift was either a personal preference or customary routine of the residents or whether the practice was acceptable to the residents, as it may require awakening sleeping residents to perform this task. Review of care plans for these residents, on the morning of 11/02/10, found the care plans addressed the need for assistance with bathing, but they did not indicate what time of day each resident preferred to bath or shower. Interview with the administrator, on the morning of 11/02/10, again revealed there was no evidence that permission had been obtained from each of these residents or responsible parties to provide showers or baths to the residents during the night shift. . | 2014-03-01 | ||
| 11421 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 279 | E | U2Q612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. Resident identifiers: #150 and #151. Facility census: 142. Findings include: a) Resident #150 Review of Resident #150's medical record found a nursing note, written at 3:20 a.m. on 11/27/10, documenting the resident was sent to the emergency room for rectal bleeding with clots. He returned to the facility on [DATE]. Review of the current care plan, on 01/06/11, found no care plan for monitoring and assessment for gastrointestinal (GI) bleeding. An interview with the DON, on 01/06/11 at 11:40 a.m., confirmed the potential for GI bleeding should have been included in the comprehensive care plan. -- b) Resident #151 Review of the medical record found that Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the current care plan, on 01/06/11 at 4:35 p.m., confirmed the care plan did not include interventions for [MEDICAL CONDITION] precautions. . | 2014-03-01 | ||
| 11422 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 425 | E | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on review of medical records, review of reports from the facility's provider pharmacy and consultant pharmacists, staff interviews, review of the facility's pharmacy policy and procedure for adverse drug reactions, review of a list of drugs with the potential to interact with Coumadin, and the manufacturer's sheet for Coumadin, it was determined the facility had not implemented pharmaceutical services procedures to minimize medication-related adverse consequences or events. One (1) resident who was receiving Coumadin was ordered Bactrim DS for an infection. The resident fell and was later hospitalized . She was found to have subarachnoid bleeding. The hospital physician identified this may have occurred due to the resident receiving Bactrim DS and warfarin (Coumadin). The records of thirty (30) residents who were receiving warfarin were reviewed. Thirteen (13) were found to have orders for medications known to have major interactions with warfarin (a blood thinner). There was no evidence the potential for interactions had been identified by the pharmacists. Additionally, the facility's pharmacy manual included a policy which included notification when there was a potential adverse drug reaction (ADR). There was no evidence this policy had been implemented for residents receiving warfarin. Resident identifiers: #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131. Facility census: 150. Findings include: a) Residents #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131 A review of residents receiving the medication warfarin was prompted by a complaint allegation. On the morning of 10/26/10, a request was made for copies of the physicians' orders for residents who were receiving warfarin. A copy of the facility's policy for adverse drug reactions was also requested. Copies of the orders for thirty (30) residents were provided the afternoon of 10/26/10. The ordered medications were compared to the lists of drugs with a potential to interact with warfarin identified on the manufacturer's drug insert. These were further reviewed via the Internet at Drugs.com. Thirteen (13) of the thirty (30) residents were found to have one (1) or more drugs listed as having the potential to have major interactions with warfarin. All thirty (30) residents were receiving medications that had a potential to interact with warfarin, ranging from minor to moderate to major. For example: 1. Resident #29 This resident had an order for [REDACTED]. She was also receiving Gemfibrozil twice a day for [DIAGNOSES REDACTED]. This medication was listed on the manufacturer's package insert as having the potential, alone or in combination, to increase PT/INR response. According to the information found at Drugs.com, this medication was known to have the potential for a major interaction with warfarin. Bactrim DS, an antibiotic, was added to the resident's medication regimen on 10/10/10 and first administered on 10/11/10. According to information found in the manufacturer's package insert and Drugs.com, this medication also had a known potential to increase the PT/INR. 2. Resident #52 This resident was also receiving warfarin. Her other medications and potential interactions included: Fenofibrate - major Fluconazole - major Lovenox - major Cymbalta - minor Levothyroxine - moderate Omeprazole - moderate Ropinirole - moderate (She had been readmitted from the hospital on [DATE]) 3. Resident #137 The resident was receiving warfarin. Ciprofloxacin was ordered for twice a day for ten (10) days on 10/19/10. Ciprofloxacin is listed as having a major potential for interacting with warfarin. - b) The facility provided a copy of a policy / procedure regarding adverse drug reactions (ADR) as requested. This included: "Warfarin Interactions a) Determine if the drug interaction potential is serious and predict the timing of the interaction effect as advised by FDB (First Data Bank) . b) Recommend an alternate medication if possible (i.e. azithromycin instead of erythromycin or clarithromycin) or determine if a warfarin dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention on Policy Form #038.3A and record any order or INR monitoring changes at the bottom as directed by the physician. c) If the interaction is NOT immediate or serious the dispensing pharmacist documents their review and assessment by overriding the hang-up in the computer and printing the FDB drug interaction sheet. d) The FDB drug interaction sheet is sent with the medication delivery or faxed to the facility. . . ." Random review of the residents receiving warfarin did not find any evidence of such notifications. The director of nursing was asked for copies of pharmacy recommendations the facility had received. She stated she had them back to May 2010. Approximately one hundred-forty (140) documents from the pharmacy to the facility were reviewed. The majority of these were regarding medication interchanges or need for hand written prescriptions for controlled substances. Only one (1) document addressing the potential for drug-drug interactions was found. This was for Resident #131. On 10/27/10, the consultant pharmacist provided a report that included, "____ takes warfarin (Coumadin) and is also on other medications which may have pharmacodynamic and / or pharmacokinetic interactions: furosemide, acetaminophen, Lexapro, metoprolol, Nexium, and Ropinirole." The recommendation included, "When changing doses, stopping or starting other medications in a resident on warfarin, please consider more frequent INR monitoring, until stable." On 11/02/10 at 12:20 p.m., the ADR policy was discussed with the director of nursing (DON). She stated the pharmacy had not been sending the notices referenced in the policy. A short while later, the DON reported they had received a list of drugs that interacted with warfarin. On 11/02/10 at approximately 4:20 p.m., Employee #192 provided a copy of the document the DON had referenced. The document listed antibiotics and anti-infectives that interacted with warfarin. Among the drugs listed under the heading "HIGH SEVERITY : Serious risk - Action must be taken" were Bactrim, Ciprofloxacin, and Fluconazole. Next to this list of medications was "Notify physician for warfarin dose reduction (as necessary) and repeat PT/INR per physician recommendation." --- Part II -- Based on review of medical records, staff interviews, review of sign-out sheets for the emergency drug box in Building 2, and a counting of the number of doses of Bactrim DS in the emergency drug box, it was determined an accurate accounting of the dispensing of medications from the emergency supply had not been ensured. Resident identifier: Unknown, but possibly Resident #29. Facility census: 150. Findings include: a) Resident #29 an order for [REDACTED]. Review of Resident #29's medical record found the antibiotic had been scheduled to be started at 9:00 a.m. on 10/11/10. However, the box for the nurse's initials on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview at 9:57 a.m. on 10/27/10, Employee #53 said she had gotten the antibiotic from the emergency box. Then she paused and said she had given Tylenol, not the antibiotic. According to documentation on the MAR, Resident #29 did not receive the first dose of the antibiotic until 9:00 p.m. on 10/11/10. On 10/27/10 at 3:35 p.m., Employee #36 was asked to provide access to the emergency box. The sign out sheets were located in the medication room. According to the sheet for October 2010, no Bactrim DS had been administered from the emergency box. The information on the sheet indicated there should have been twenty (20) doses of Bactrim DS in the box. An actual count of the medication found there were nineteen (19) doses, not twenty (20) doses of Bactrim DS in the emergency box. It was unknown to whom the medication had been given. . | 2014-03-01 | ||
| 11423 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 153 | D | U2Q611 | . Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, "You Have the Right To:" The first item under this title stated, "1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing." The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's records until after the hearing on 09/27/10, and she produced a release signed by the resident's legal representative on that date. . | 2014-03-01 | ||
| 11424 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 309 | G | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was "secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after the initial assessment occurred shortly after the fall on the morning of 10/14/10, the physician was not notified of the fall or subsequent bruising to the resident's temple until the afternoon of 10/15/10, and no one at the facility recognized and/or was monitoring the resident for increased anticoagulant effects associated with administering Bactrim DS with [MEDICATION NAME]. Resident identifier: #29. Facility census: 150. Findings include: a) Resident #29 Record review revealed this [AGE] year old female was admitted to the facility in 2002. Her active [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) 6.5 mg and 7 mg alternating every other day, according to the physician's monthly recapitulation of orders for October 2010. Review of a lab report, dated 10/07/10, for [MEDICATION NAME] time (PT) and international normalized ratio (INR), both of which were used to evaluate blood clotting time, found the PT to be high at 28.5 (normal range is 11.9 - 25.4) and the INR to be within normal limits (WNL) at 2.7 (normal range is 2.0 - 3.0). The physician was notified and ordered the same dosage of [MEDICATION NAME] with a recheck of labs in four (4) weeks. Previously, on 09/07/10, Resident #29 ' s PT was elevated at 25.9 and her INR was WNL at 2.1, and no change in medication was ordered. Review of the nursing notes found an entry, dated 10/10/10 at 6:15 p.m., stating the physician was notified that the resident had an increased temperature of 101.9 degrees Fahrenheit (F). The physician ordered Tylenol 500 mg and a urinalysis (UA) and complete blood count (CBC) stat. The results were called to the physician on 10/10/10 at 11:00 p.m., and the physician ordered Bactrim DS was ordered twice daily for seven (7) days. Her temperature at this time was 98.7 degrees F. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/10 at 1530 (3:30 p.m.), the nurse's notes indicated the resident's legal representative was notified of the resident having a urinary tract infection, of her increased temperature on 10/10/10, and of the new order for Bactrim DS. The resident's temperature at this time was noted at 97.0 degrees F. On 10/13/10 at 1:00 a.m., the nursing notes indicated the resident's was not having any signs or symptoms of adverse reactions associated with the use of the antibiotic. She remained afebrile, denied pain / discomfort, and was resting in bed with eyes closed. The next nursing note, written by a licensed practical nurse (LPN - Employee #137) and dated 10/14/10 at 7:20 a.m., stated, "Res(ident) found in floor @ bottom of bed. Res states she is OK, no visible injuries.... Res states she was going to the bathroom and fell , bed alarm was not on. Assessment completed, (symbol for 'no') c/o (complaint of) pain or discomfort. Will continue to monitor." In this same note, the nurse recorded her vital signs as follows: blood pressure (B/P) - 138/78; pulse - 78; respirations - 18; temperature - 98.8 degrees F; O2 sat was 93% on room air. Oxygen was reapplied, and her O2 sat was 95%. The next nursing note, written by a registered nurse (RN - Employee #166) and dated 10/15/10 at 3:20 p.m., stated, "Staff report pt (patient) had fall on 10/14/10. Noted bruising /c (with) hematoma to (L) (left) temporal area. Appeared to have difficulty opening (L) eye. Resident alert & speech clear. Pupils equal & reactive. B/P this am (morning) 136/64, O2 sat 90%, (pulse) 86, (respirations) 18. Dr. (name) notified & made aware of current status. Dr. (name) stated he was unaware of fall. New order received to send resident to (Hospital #1) ER for evaluation. Resident is currently on blood thinner. POA (power of attorney) was notified." The next nursing note, dated 10/15/10, at 4:15 p.m. stated, "TC from (Hospital #1) ER. Resident being sent to (Hospital #2); has a subarachnoid bleed." -- 2. Review of Hospital #1's records found Resident #29 had critical lab values of PT greater than 100 (normal range is 20.5 - 30.0, with critical values greater than 39), INR of 11.9 (normal range is 2.5 - 3.5, with critical values greater than 4.0), and PTT (partial [MEDICAL CONDITION] time) of 83 (normal range is 27 - 32) on 10/15/10 at 1526 (3:26 p.m.). The resident's red blood cells were low at 3.61 (normal range is 4.5 - 6.3), hemoglobin was low at 11.6 (normal range is 12.1 - 15), hematocrit was low at 33.9 (normal range is 35.8 - 46). The results of a CT scan of Resident #29's brain without contrast, dated 10/15/10, noted: "Findings: There is punctate hemorrhage of the left frontal lobe. There is no extra axial component. There is a large, left frontal scalp hematoma. Sulcal and ventricular prominence correlation with atrophy. There is no midline shift. There is no calvarial fracture." Under the heading CT Brain Impression was: "1. Acute left frontal lobe parenchymal hemorrhage. 2. Generalized cerebral atrophy. 3. Large, left, frontal scalp hematoma." The resident received 8 units of fresh frozen plasma and 30 mg of Vitamin K and was transferred to Hospital #2's neurology intensive care unit for a neurosurgical consultation on 10/15/10; she was subsequently admitted there at 2352 (11:52 p.m.), according to Hospital #2's discharge summary. -- 3. The discharge summary from Hospital #2, dated 10/20/10, under the heading Admission History and Physical stated: "This was a transfer from (Hospital #1). The patient initially is a resident at Heartland of Beckley. The patient apparently fell down. The patient was not taken to the hospital at that time. After a day (sic) refer to consultation with the family. The patient was sent to (Hospital #1). At Hospital #1, the patient was found to have (sic) subarachnoid hemorrhages. The patient was subsequently transferred to the Neuro ICU here at (Hospital #2) for neurological evaluation. On presentation to (Hospital #1), patient ' s blood pressure was 170/74. The patient's INR was noted to be 11.9. The patient did receive a course of Bactrim previously while at Heartland of Beckley." Under the heading Hospital Course was stated, "... I believe patient's subarachnoid hemorrhage is secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." -- 4. Review of the resident's resident assessment protocol (RAP) for falls with an effective date and time of 06/29/10 at 11:09 a.m. stated, " ... resident was walking back from bathroom and slid and fell (sic) improper footware (sic) pt educated on use of proper footware (sic) improper footware (sic) removed (sic) assessed for injury (sic) none noted (sic) neuro checks started (sic) md and poa aware." An off-cycle falls RAP, with an effective date of 10/14/10 at 08:34 a.m., was completed by one (1) of the assistant directors of nursing (ADON - Employee #192) and signed on 10/16/10. It stated, "Fall care plan reviewed and remains in place. No new recommendations made during IDT (interdisciplinary team) review." - The Care Plan Focus for "At risk for falls due to Cognitive (sic) impairment, pain, unsteady gait, walks without assistance, low oxygen saturations from not wearing oxygen, [MEDICAL CONDITION]", which was initiated on 04/11/07, contained the goal of "No injury requiring transfer to hospital." The following interventions to achieve this goal were initiated on 04/11/07: "Monitor for and report development of pain, bruises, change in mental status, ADL function, appetite or neurological status for at least 72 hours after a fall. Administer medications as ordered and monitor for effectiveness. Minimize environmental clutter. Have commonly used articles within easy reach. Encourage to transfer and change positions slowly. Reinforce need to call for assistance. Encourage and assist as needed to wear proper and non slip footwear. Encourage to use assistive devices: walker." On 10/04/07, the IDT added: "Give medication as ordered." On 12/31/08, the IDT added: "Educate staff to not leave resident unattended." On 06/25/09, the IDT added: "Educate resident on the use of call light and asking for assistance." On 09/24/09, the IDT added: "Sensor pad to bed at all times." On 10/18/09, the IDT added, "Anti-rollbacks to W/C (wheelchair)." On 03/19/10, the IDT added: "non (sic) skid shoes as tolerate (sic)." (Note that several of the "newer" interventions were very similar to interventions that had been in place since 04/11/07.) - The Care Plan Focus for "Anticoagulant therapy to treat [MEDICAL CONDITION]: At risk for adverse effects", which was initiated on 04/11/07, contained the goal of "Resident will have no adverse effects from anticoagulant use such as (sic) not limited to bruising, bleeding, blood in stool / emesis, etc." Interventions to achieve this goal included: "Monitor lab values and report results to physician. Monitor for and reports (sic) adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Provide education to family / resident about safety precautions. Administer medications per physician orders. Monitor for S/S (signs / symptoms) of [MEDICAL CONDITION] such as pain (sic) redness in ext (extremities)." The last revision to this care plan was made on 10/27/09, beyond updating to the goal ' s target date. -- 5. The LPN who received the order from the physician on 10/10/10 at 11:00 p.m. (Employee #53) was interviewed at 9:57 a.m. on 10/27/10. Employee #53 said when she called the physician she did not tell him specifically what medications the resident was already receiving. She said the pharmacy usually calls before sending a medication if there would have been any problems with drug-to-drug interactions. - The nursing assistant (NA) who showered Resident #29 on day shift on 10/14/10 (Employee #31) was interviewed at 10:20 a.m. on 10/27/10. Employee #31 reported that, after lunch on 10/14/10, she noted a knot on the resident's head and bruising to the resident's hand, and the resident told her she fell . She said when she was on the way to the shower with the resident, she told the medication nurse (Employee #82, an LPN). He looked at the resident's head, administered a medication to the resident, and the resident was given a shower. Employee #31 said the resident was taken back to her room. She did note that the resident appeared to be having increased congestion. A review of Employee #31's statement taken by the director of care delivery (Employee #192) on 10/16/10 found the following: "States she took over care of resident on 10/14 AM (morning) when other CNA (certified nursing assistant) was pulled to another unit. State she saw a large raised area with a bruise stating to form on resident's (L) temple area. States this was around noon, during resident ' s shower. States she brought it to the attention of the nurse '(Employee #82 ' s first name)'. States resident's behavior was normal & speech was normal." Review of the Shower / Skin Observation Report for 10/14/10, completed by Employee #31 and signed by Employee #82, did not show any bruising or abnormalities for the resident. - The LPN who assessed Resident #29 after she was found on the floor at 7:20 a.m. on 10/14/10 (Employee #137) was interviewed at 10:25 a.m. on 10/27/10. She reported having been told of the fall by a NA (Employee #93) at the start of the shift. She said the resident was sitting in the floor upright with her legs out in front of her. The bed alarm was not on and was not sounding. She said she did a head-to-toe assessment of the resident and found no bruising or signs of injury. She indicated she checked the resident's head, back, and legs, as she was afraid the resident might have broken a hip. She also said she thought she started a neurological evaluation flow sheet but was told it could not be found. A review of Employee #137's statement taken by Employee #192 on 10/14/10 at 0830 (8:30 a.m.) found the following: "Nurse stated that resident had a fall around 0730 and that she found no apparent injuries. Stated resident denied any pain or discomfort. States she notified Dr. (name) and MPOA (medical power of attorney) of the fall and completed an incident report. State she initiated neuro checks because the fall was not witnessed. No noted abnormalities at that time." Elsewhere in witness statement for was written: "Staff member became ill shortly after the incident and was taken to the hospital by EMS. Unable to locate neuro check sheet." - The resident's October 2010 MAR indicated [REDACTED]. Review of the MAR for 10/14/10 found Employee #82 only gave the resident [MEDICATION NAME] 100 mg at 2:00 p.m. on that date, as he was reassigned to that area when Employee #137 was sent out to the emergency room . He stated, "(Employee #31) said the resident had a bruise on her head. I looked at it. I went out and looked at the book for acute documentation. I did not know if it was documented. I don't recall saying anything to (Employee #134) who I reported off to (at 3:00 p.m.)." A review of Employee #82's statement taken by Employee #192 on 10/16/10 found the following: "Stated he took over med cart for nurse that left due to illness, along with (Employee#134), LPN. States he did note a bruise to the L temple area of the resident, but (sic) had been told it was already there from a fall. States he did not know when the fall occurred." - An interview was conducted, on 10/27/10 at 11:30 p.m., with the LPN who received report from Employee #82 at 3:00 p.m. on 10/14/10 (Employee #134). Employee #134 said she worked from 7:30 to 4:00 p.m. on 10/14/10 as a treatment nurse. The October 2010 treatment record was reviewed with her at this time. She said she checked the resident's sensor pad and oxygen on 10/14/10, but she did not remember at what time. She thought it was before breakfast (before 8:30 a.m.). She reported that she helped Employee #82, after Employee #137 was sent out to the emergency room , with medications and doing treatments. She did not know anything about the resident's fall on 10/14/10. - A review of a statement taken from Resident #29 by Employee #192 on 10/15/10 revealed the following: "Resident sitting up on side of bed. Bruising noted to (L) temple / forehead area. Resident alert and answering appropriately to my questions. When asked if she had any pain, she answered, 'my head'. When asked if she remembered fall she stated, 'I'm not sure'. When asked where her head hurt she stated 'Inside and out'. Resident sent to (Hospital #1) within 30 minutes of my conversation with her." - A review of a statement taken from Employee #72 (a nursing assistant) by Employee #192 on 10/15/10 revealed the following: "CNA states that she noted a bruise to the (L) temple area of the resident around 0830 (8:30 a.m.) on the morning of 10/15/10 when she took her breakfast tray to her. States that the nurse was aware of the bruise at that time." - A review of a statement written on 10/18/10 by Employee #166 (a registered nurse assigned to Resident #29 on the morning of 10/15/10) revealed the following: "I had a wing and part of another wing (we were short nurses). I received report from night shift (name). No mention of a fall or injury to the resident was made during report. I gave her morning meds first. I noticed bruising to the left side of her temple area. I took her VS (vital signs) and they were normal. I had to wake her to take her meds. She was 'groggy' but sat up and took her pills for me. I questioned some other staff and they stated she had a fall the morning before. I assumed her bruising was from the fall. When I reviewed the chart there was no documentation of any injury. I recognized the resident was on [MEDICATION NAME]. I went to assess her neurologically and found her to be WNL but C/O pain to (L) eye. I notified Dr. (name) of fall (sic) 10/14 & injury noted @ this time. Dr. (name) stated he was not notified and asked that resident be sent to ER." -- 6. Review of the pharmacy manual's policy titled "Adverse Drug Reaction" from Omnicare, Inc (last revised 01/10/06), which was provided by the facility ' s administrator at approximately 9:00 a.m. on 10/27/10, found: "ROCEDURE: The pharmacy will identify potential ADRs (adverse drug recations) by reviewing any drug therapy that appeared to cause: - Discontinuation of therapy - Patient hospitalization - Treatment with another drug used for allergic reactions - Significant patient illness - Threat to life or death. "The pharmacist will document the potential adverse drug reaction on the Adverse Drug Reaction Log ... noting severity level. "The pharmacy operating system is set to identify First Data Bank (FDB) levels 1, 2, and 3 drug interactions for the dispensing pharmacist at the time of order entry. "The dispensing pharmacist evaluates the potential seriousness and immediacy of the drug interaction in the individual using their professional judgment and the information provided by FDB. Factors such as the person's age, comorbidities, and concurrent drug therapies area taken into consideration ..." "[MEDICATION NAME] Interactions: "a) Determine if the drug interaction potential is serious and predict the timing of the interaction as advised by FBD. "b) Recommend an alternate medication if possible ... or determine if a [MEDICATION NAME] dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention ...." -- 7. Review of the facility's policy titled "Neurological: Neurological Evaluation" (dated 3/2010) found: "PURPOSE: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluation may be compared and changes in neurological status may be determined. "USE: - Following a witnessed fall (when a patient has hit his/her head) - Following an un-witnessed fall (when a head injury may be suspected) - Following a patient event which results in a known or suspected head injury (i.e.: hemorrhagic stroke) ... "PROCEDURE: "1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. "2. Notify physician of specific patient event, initial findings, and baseline neurological evaluation. "3. Obtain orders for subsequent neurological evaluations, diagnostic studies or other medical care. "4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x 4, then every 1-hour x 4, then every 8-hours x 9 (for the next 72 hours). "NOTE: More frequent neurological evaluations may be necessary if clinically indicated or as ordered per physician. "5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations. "6. Evaluate level of consciousness and document 'Y = Yes or N = No' responses to the following: - Alert - Lethargic - Semi-comatose - Comatose "7. Evaluate level of orientation and document 'Y = Yes or N = No' responses to the following: - Oriented to person - Oriented to place - Oriented to situation "8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil reaction for both the left and right eyes. Document using the following responses: - E = equal pupil size - U = unequal pupil size - R = reacts to light - NR = no reaction to light "9. Evaluate motor movement by providing patient with simple motor commands. Document 'Y = Yes or N = No' responses to the following: - Moves right upper limb - Moves left upper limb - Moves right lower limb - Moves left lower limb - Facial symmetry "10. Evaluate communication / language by providing simple communication commands. Document 'Y = Yes or N = No' responses to the following: - [MEDICAL CONDITION] - Receptive [MEDICAL CONDITION] - Speech slurred - Communication changes "11. Evaluate for unusual / new observations. Document observation responses using the following: - W = Weakness - T = Tremors - D = Dizziness - H = Headache - V = Vision changes - N = Numbness - O = Other "12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: - Blood pressure - Pulse - Pulse Ox % (Oxygen Saturation) - Temperature - Respiration rate - Respiration pattern -- N = Normal / Regular / Unlabored -- AB = Abnormal (i.e.: Labored, Kussmaul's , Cheyne-Stokes or Apnea) "NOTE: Pay close attention to respiratory patterns. Notify physician regarding any 'Abnormal' findings or any changes in respiration rate or pattern. "NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations. Document physician notification in Progress Notes. "13. Notify the family / caregiver of patient condition an devaluation findings. "14. Communicate event, interactions, and plan of actions using center specific systems (i.e. shift to shift reports, 24-Hour Reports, Eagle Room team meeting and alert charting)" - Random confidential nursing staff interviews found that evidence of ongoing neurological evaluations of Resident #29 could not be found. Although Employee #137 (who first assessed her after she was found on the floor on the morning of 10/14/10) reported she completed an initial neurological exam, evidence of that initial assessment could not be found. This lack of on-going neurologic assessments was confirmed during an interview at exit with the facility administrator at 4:30 p.m. on 11/02/10. -- 8. The facility's "Practice Models Charting Alert" (dated 08/11/06) stated: "Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status "Guidelines: The alert charging process includes documentation of a patient's condition that warrants alert charging, the decisions and actions of staff related to the patient's condition and the patient's response to interventions implemented - Situation for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within. Some examples may include, but are not limited to: -- Change of condition, e.g. flu symptoms -- Accidents -- New admission or re-admissions -- Signs and symptoms of infection -- Skin alterations, e.g., skin tear, bruise, rash - The Alert Charting process includes, but is not limited: -- Documentation of patient evaluation findings, physician notifications and responses, family notification and any new orders or instructions received in the interdisciplinary progress notes or nursing notes -- Initiation of an Acute Care Plan including the patient ' s problem or need, goal, and interventions planned to manage the patient ' s condition -- Addition of patient name and information to the Alert Charting Log -- Update to the Change in Status Report, 24-hour Report -- Inclusion of information in shift-to shift report -- Notification of nurse supervisor, IDT members and other staff as needed -- Review of patient status during Eagle Room meetings - Documentation for alert charting occurs each shift for a minimum of 72 hours - Licensed nurses reference the Alert Charting Log at the start of each shift to identify patients requiring continued follow-up and alert documentation - Documentation related to the alert charting process may include, but is not limited to: -- Patient evaluation pertinent to the condition identified as the acute event -- Vital signs -- Presence or absence of pain -- Complaints and/ or behavior problems -- Changes in activities of daily living -- Patient response or outcomes - Remove patients form Alert Charting Log and discontinue Acute Care Plan when patient status has stabilized or the condition or symptom has resolved." There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. Review of the "Change In Status Worksheet / 24 Hour Report" for 10/10/10 through 10/14/10 revealed no mention of Resident #29's condition and/or status except for on 10/10/10, when a nurse wrote: "Give Tylenol 500 mg PO now D/T (due to) increased temp. U/A and CBC stat." - The "Change In Status Worksheet, 24-Hour Report Practice Model" (dated 08/11/06) stated: "Purpose: To provide an interdisciplinary communication tool that may be used to identify patient with a change in condition requiring intervention and follow-up. "Guideline: "- Complete form per directions and use narrative section for additional information as needed "- Information includes but is not limited to: -- Admissions -- Unplanned discharges -- Change in condition, e.g. improvement or deterioration in physical, mental and psychological status -- Unstable condition -- Incidents / accidents -- New / discontinued medication orders -- Abnormal lab results -- Pain level > or = 4 -- Patient / family concerns -- Notification of physician, family / responsible party, administrator and/or ADNS -- Documentation completed: Nursing admission evaluation, off-cycle RAP, progress RAP, progress notes -- Nurse's initials "- Interdisciplinary team members may enter any identified change of condition requiring clinical follow-up "- Use report to communicate concerns at morning and after Eagle Room meetings "- Use report during shift change to communicate patient information and needed follow up "- Review report to confirm follow-up, notification and documentation of patient needs are complete" - There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. -- 10. Review of the pharmacy manual's "Policy #4.1 Prescriber Authorization and Communication of Orders" (dated 12/01/07) found: "PROCEDURE: " ... 3. Verbal Orders: "3.1 The facility's licensed nurses should contact the resident's physician where there is a change in condition that may require a new medication or a renewal of an existing order. "3.1.1. Before contacting the physician / prescriber, the Facility's licensed nurses should assemble the necessary clinical information. This information may include, but is not limited to: vital signs, recent laboratory or diagnostic study results, recent medication orders, residents' response to medication, and possible adverse drug reactions." No one at the facility recognized the possible adverse drug reaction associated with simultaneously administering Bactrim DS with [MEDICATION NAME]. . | 2014-03-01 | ||
| 11425 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 520 | E | U2Q612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's quality assessment and assurance committee failed to identify quality deficiencies of which it was (or should have been) aware and develop and implement plans of action to correct these quality deficiencies. This resulted in the facility's continuing non-compliance with the Medicare / Medicaid conditions of participation. During the current survey from 01/03/11 through 01/07/11, the facility failed to correct deficient practices cited during previous survey events that concluded on 09/01/01 and 11/02/10, with respect to the following regulatory requirements: Comprehensive Care Plans (F279), Quality of Care (F309), and Pharmaceutical Services (F425), resulting in repeat deficiencies in these areas. These deficient practices affected three (3) of ten (10) sampled residents and presented the potential for more than minimal harm to more than an isolated number of residents at the facility. Resident identifiers: #150, #151, and #152. Facility census: 142. Findings include: a) Quality of Care 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Quality of Care (F309) resulting in findings of deficiencies at a level of actual harm to an isolated number of residents during two (2) previous survey events at the facility, which concluded on 09/01/10 and 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. 2. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. 3. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. (See also citation at F309.) -- b) Pharmaceutical Services (F425) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Pharmaceutical Services (F425) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. 2. Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident did not receive her first dose of [MEDICATION NAME] at the facility until the evening of 12/12/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. 3. Resident #152 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident missed twelve (12) scheduled doses of [MEDICATION NAME] between 6:30 p.m. on 12/02/10 and 9:00 a.m. on 12/06/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. (See also citation at F425.) -- c) Comprehensive Care Plans (F279) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Comprehensive Care Plans (F279) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. 2. Resident #150, who was sent to the emergency room at a local hospital on the early morning of 11/27/10 for rectal bleeding with clots, did not have a current care plan (as of 01/06/11) to address the need to assess and monitor for [MEDICAL CONDITION]. 3. Resident #151, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. (See also citation at F279.) | 2014-03-01 | ||
| 11426 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 309 | G | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. These practices had the potential to result in more than minimal harm to an isolated number of residents. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her nursing notes revealed the following consecutive entries: - The admission nursing note, dated 11:00 p.m. on 12/10/10, stated,"... Resident appeared anxious and wanted to call her niece. The Resident (sic) phone was given to Resident and this appeared to have a calming affect (sic). ... VS (vital signs) are WNL (within normal limits) excluding pulse possibly D/T (due to) anxiety experienced when first arriving. ... Resident is A/O (alert / oriented) x's (sic) /c (with) confusion noted. ... All meds sent to pharmacy STAT and pharmacy was notified and stated they would be sent. ... There appear to be (symbol for 'no') s/s (signs / symptoms) of acute distress noted at this time. ..." - A nursing note, dated 12/11/10 at 11:45 a.m., stated,"... Alert / oriented to person, place and time, But (sic) does not answer questions appropriately. (Arrow pointing up) confusion to situation / reasons for being admitted to HL (Heartland). ..." - A nursing note, dated 12/11/10 at 11:41 p.m., stated, "OT (occupational therapy) orders noted ..." - A nursing note, dated 12/11/10 (time illegible), stated, "Res (resident) OOF (out of facility) until approx 1130 - 12 noon. Ref (refused) shower upon arrival. 'I just got back from the Hospital.' ..." - A nursing note, dated 12/13/10 at 11:45 a.m., stated, "A/O x 3 (alert and oriented to person, place, and time). Confusion noted, Demanding (sic) argumentative (illegible) meds, explained med regimen several times /s (without) success D/T confusion." - A nursing note, dated 12/13/10 at 4:30 p.m., stated, "Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about [MEDICATION NAME] & [MEDICATION NAME]. pharmacy (sic) states that a script is needed for [MEDICATION NAME] & [MEDICATION NAME] had been sent. ..." Review of the resident's physician orders [REDACTED]." Review of Resident #151's hospital records revealed the physician who examined her wrote in the ER, under the heading "Clinical Impression", "Anxiety / Panic Attack". She was treated with intravenous [MEDICATION NAME] and returned to the facility at approximately 11:30 a.m. on 12/11/10. Review of the admitting orders found the resident was prescribed [MEDICATION NAME] 1 mg twice-a-day (bid) for anxiety and [MEDICATION NAME] (generic name for [MEDICATION NAME]) 50 mg at bedtime for depression / anxiety. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials documented at 10:00 p.m. with the following statement, "Refused all pm (evening) meds (medications) because [MEDICATION NAME] & depression med was not available." Review of the MAR found the resident also did not receive her 9:00 a.m. dose of [MEDICATION NAME] 1 mg on 12/12/10. After her return to the nursing facility on 12/11/10 (after having been treated with IV [MEDICATION NAME] for anxiety / panic attack), the facility failed to obtain and administer two (2) consecutive scheduled doses of [MEDICATION NAME] to treat her anxiety. She did not receive her first dose of [MEDICATION NAME] at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's [MEDICATION NAME] until 9:25 p.m. on 12/12/10. -- b) Resident #152 1. Review of Resident #152's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. According to recent assessment data, she was alert / disoriented to person, place, and season, had short and long-term memory impairment, and her cognitive skills for daily decision-making were moderately impaired. She was totally dependent on staff for the performance of all activities of daily living, had partial loss of voluntary movement with limitations in range of motion on both sides in her upper and lower extremities, and was incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. Further review found the resident was receiving [MEDICATION NAME] 5 mg (blood thinner) daily, which placed her at high risk for bleeding. - Review of Resident #152's nursing notes found the resident was readmitted to the facility on [DATE], following treatment in the hospital for UTI [MEDICAL CONDITION]; her [DIAGNOSES REDACTED]. She went back out to the hospital on [DATE] for the insertion of a gastrostomy tube and returned to the facility again on the evening of 12/20/10. According to a nursing note dated 12/26/10 at 12:30 a.m., "Resident sent to (initials of local hospital) ER (emergency room ). Order received via telephone from Dr. (name of physician). See SBAR (Situation / Background / Assessment / Request form)." The next consecutive note, dated 12/26/10 at 7:10 a.m., stated, "Called (initials of local hospital) ER. Resident admitted to (initials of local hospital) D/T (due to)[MEDICAL CONDITION], mental status change, & respiratory compromise." Review of the electronic form referred to as the "SBAR", dated 12/26/10 at 12:45 a.m., found under the heading "Situation": "O2 sats (blood oxygen saturation levels) decreased to 72% with O2 @ 2.5L NC (oxygen at 2.5 liters / minute via nasal cannula). airways (sic) suctioned (sic) O2 (sic) increased to 80%. NEB (nebulizer) tx (treatment) administered. Lung sounds congested. O2 icreased (sic) to 3L via NC S (sic)." Under the heading "Background", the author noted that medical information pertinent to this event included, "Fall on 7p-7a (7:00 p.m. to 7:00 a.m.) shift on 12/24/2010, recent peg tube placement, increased temp of 101.0." The author also noted the resident had exhibited a decrease in her level of consciousness, and increased heart rate of 148 beats per minute with an irregular rhythm, wheezes when checking her lung sounds, and the resident's skin color was pale. Under the heading "Assessment (RN) / Appearance (LPN/LVN)", the licensed practical nurse (LPN) completing the form noted, "Resident (sic) skin warm, clammy. Pale in color. SOB (shortness of breath) noted." Under the heading "Request", the author noted having contacted the resident's physician and obtaining an order to "Send resident to (initials of local hospital) ER. " Review of the resident's physician progress notes [REDACTED]. ("Rhonchi" or "wheezes" are abnormal breath sounds caused by air moving through airways narrowed by [MEDICATION NAME], swelling, or partial airway obstruction.) Review of nursing notes from her previous stay, from 12/02/10 to 12/13/10, revealed the resident was congested and required suctioning and aerosolized breathing treatments, with deep suctioning and a chest x-ray ordered on [DATE]. Review of her current care plan, with a print date of 09/01/10, revealed the following problem statement: "Potential for respiratory impairment related to [MEDICAL CONDITION]." The goal associated with this problem statement was: "Resident will have no acute episodes of respiratory distress such as, but not limited to SOB, dyspnea, cyanosis, aspiration (sic)." Interventions to assist the resident in achieving this goal included: "... Monitor lung sounds and VS (vital signs) as needed. Report abnormalities to physician. ... Monitor for and report adverse changes in respiratory rate, cough, respiratory effort, sputum color / consistency. ... " Review of nursing notes from the date of her readmission to the nursing facility on 12/21/10 until her transfer to the hospital on [DATE] found no evidence to reflect the licensed nursing staff was routinely assessing / monitoring the resident's respiratory system for abnormal breath sounds after the physician identified the presence expiratory rhonchi, although the licensed staff periodically noted the resident's respiratory rate and blood oxygen saturation levels. - Further review of the resident's current care plan found the following problem statement: "Urinary incontinence related to effects of [MEDICAL CONDITION]." The goal associated with this problem statement was: "Will have no complications due to incontinence such as, but not limited to UTI, skin breakdown (sic)." Interventions to assist the resident in achieving this goal included: "...Monitor for and report any changes in amount, frequency, color or odor of urine or continency (sic). ... Monitor for and report any S&S (signs and symptoms) of UTI such as flank pain, c/o (complaints of) burning / pain, fever, change in mental status, etc ..." The medical record contained no nursing notes or other evidence that licensed nursing staff was assessing / monitoring the resident for signs and symptoms of UTI. - The resident was admitted to the hospital on [DATE] with a temperature of 101.0 degrees Fahrenheit (F); the resident's hospital [DIAGNOSES REDACTED]. - 2. Review of Resident #152's medical record found a nursing note, dated 12/05/10 at 2:30 p.m., documenting that Resident #152 sustained a witnessed fall. A nursing note, dated 12/07/10 at 10:00 p.m., documented the following, "... Resident did have a fall on 12/5/10 at 2:30 p.m. Neuro Checks started at 10 pm to rule out neurological damages..." Because of her daily use of [MEDICATION NAME], Resident #152 would have been at high risk for intracranial bleeding if she had struck her head as a result of this fall. Review of the neurological evaluation flow sheet found that nursing staff did not begin monitoring the resident for potential neurological compromise until 10:00 p.m. on 12/07/10, approximately fifty-five (55) hours after the resident's fall. In an interview was conducted on 01/07/11 at 3:45 p.m., the director of nursing (DON - Employee #15) was asked when nursing staff should have started neuro checks after the resident's fall. The DON stated that neuro checks should not have waited and staff should have started them immediately. - 3. Medical record review also revealed Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with a [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to the facility's failure to obtain pharmaceutical services in a timely manner. . | 2014-03-01 | ||
| 11427 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 425 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admitting orders found the resident was prescribed Xanax 1 mg twice daily for anxiety and Doxepin 50 mg at bedtime for depression / anxiety. Review of her nursing notes revealed a note, dated 12/13/10 at 4:30 p.m., stating, "Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about Xanax & Sinequan. pharmacy (sic) states that a script is needed for Xanax & Sinequan had been sent. ..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the back of the MAR found a nurse's initials documented at 10:00 p.m. with the following statement, "Refused all pm (evening) meds (medications) because Xanax & depression med was not available." Further review of the MAR indicated [REDACTED]. She did not receive her first dose of Ativan at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's Xanax until 9:25 p.m. on 12/12/10. -- b) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no Xanax from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving Xanax. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered Xanax due to the facility's failure to provide pharmaceutical services in a timely manner. . | 2014-03-01 | ||
| 11428 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-11-11 | 241 | D | 6V1A11 | . Based on observation, resident interview, and staff interview, the facility failed to promote care for one (1) of four (4) residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Observation and interview revealed one (1) resident did not receive prompt assistance with incontinence care during a meal time. Resident identifier: #77. Facility census: 141. Findings include: a) Resident #77 Observation, on 11/11/10 at approximately 8:35 a.m., found Resident #77 turned on his call light. When interviewed, he reported he needed to be cleaned up. The resident said, "I am in a mess." At approximately 8:40 a.m., the resident's call light went off. At approximately 8:45 a.m., Employee #130 (a nurse aide) said she told the resident she would clean him up after she finished picking up the breakfast trays. On 11/11/10 at approximately 10:45 a.m., the interim director of nursing indicated he had spoken with this nurse aide, and Employee #130 did realize she should have provided Resident #77 with the assistance he needed before she finished picking up the breakfast trays. He agreed the resident's needs should have come before picking up trays after the breakfast meal. . | 2014-03-01 | ||
| 11429 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 314 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a "blackened area" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as "10", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: "Potential risk for skin breakdown d/t (due to) decreased physical mobility." The goal associated with this problem statement was: "Maintain intact skin integrity thru 09/21/10." Approaches to be implemented to meet this goal included: "up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode." -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading "Describe Circumstances of the Incident (Be very specific):" was written, "CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times." Under the heading "Analysis of the Incident: (apparent cause)" was written, "Poor bed mobility." Under the heading "Describe Corrective action (sic) or Protective Action Taken: (be specific)" was written: "[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times." -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following "Uses" for [MEDICATION NAME]: - "Management of decubitus ulcers." - "Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. " - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: " The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. " -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, "We do weekly body audits." When further questioned about how an area would not be recognized until it had become black, the nurse stated, "It should have been caught before it was black." . | 2014-03-01 | ||
| 11430 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 157 | D | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed, for one (1) of eleven (11) sampled residents, to notify the resident's legal representative or attending physician of a significant change in the resident's health status. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs and failed to collect / record, monitor, and report to the physician or the resident's legal representative any physical assessment data related to this resident's change in condition. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 5. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's legal representative. -- 6. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 7. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 stated, "Her daughter came to me and said she was acting different, and I sent her to the hospital." Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. . | 2014-03-01 | ||
| 11431 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 309 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - "N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted." - On [DATE] at 11:00 a.m. - "S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor." - On [DATE] at 12:05 p.m. - "Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor." According to the hospital history and physical, "... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had "diarrhea for several days" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under "Nursing Actions: Physical Assessment" on page 704: "Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..." Under "Nursing Actions: Patient Education" on page 704: "... Report persistent or severe diarrhea or abdominal cramping ..." Under "Geriatric Considerations" on page 704: "Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...." - For Senna Plus, under "Nursing Actions: Patient Education" on page 385: "...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..." -- 7. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, "Her daughter came to me and said she was acting different, and I sent her to the hospital." -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: "Resident is at risk for constipation: limited mobility; medications; history of constipation." The goal associated with this problem statement was: "Resident will have bowel movments (sic) at least every three day s (sic) thru next review." Interventions to achieve this goal included: "Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order." - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]." There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. . | 2014-03-01 | ||
| 11432 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 327 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. (See citation at F309.) -- 5. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer them except when the resident refused. (See also citation at F309.) -- 6. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 7. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. . | 2014-03-01 |