CMS-Nursing-Home-Full-Deficiencies
Data source: Big Local News · About: big-local-datasette
This data as json, copyable, CSV
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 600 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, abuse and neglect policy review, staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to provide necessary care and services to Resident #92 in preparation for scheduled appointments outside of the facility, of which the facility was aware of or should have been aware. The facility also failed to provide Resident #92 care and services in the care areas concerning baths and shaving. This was true for one (1) of six (6) sample residents dependent for care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Scheduled appointments outside of the facility Resident #92 is a paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. He is totally dependent for all care, is legally blind, and newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of records on 02/05/18 at 2:55 PM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) 01/04/18. The resident had impaired vision (legally blind); had clear speech, was able to understand and make himself understood. The MDS revealed a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident was cognitively intact. Resident #92 needed extensive assistance with eating and was dependent for all other activities of daily living (ADL) including bed mobility, transfer, dressing, toileting, and hygiene. The resident was on scheduled and as needed pain medication and had not had a fall during the seven day look back period. Resident received speech therapy, occupational therapy, and physical therapy. Observations, on 02/05/18 at 11:55 AM., revealed Resident#92 appeared clean, without any body odors, hair stubble noted on chin, and Foley catheter was draining to drainage bag on bedside. The bed rails properly fit the bed. The resident had a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands. Blow call light was within reach of the resident and he was observed using it with staff responding timely. Resident#92 did not want to be interviewed at the time the surveyor attempted an interview, and this surveyor told the resident the surveyor would come back the next day to talk to him. The next day when this surveyor went to interview Resident #92, the resident was no longer a resident at the facility, Resident #92 was transferred to live at another facility and was unavailable for interview On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. The report revealed, Per VA the resident stated his head hitting side rail on bed and he was yelling. Someone came and shut the door but did not provide care. The results of the facility's reportable investigation revealed the allegations were unsubstantiated due to lack of information provided by EMS. The facility requested an extension for five day follow up from 12/31/17 to 01/05/18, due to awaiting statements from EMS. Review of the facility's five day follow up report findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The NA did clean the resident and emptied his catheter, after being told by a nurse to clean him up for his appointment after the EMS ambulance crew arrived to pick up the resident. Breakfast had not been served yet. The social worker (SW#68) noted that EMS had been contacted multiple times, requesting statements concerning the description of the incidence (the facility reported they did not receive EMS statements). Social worker SW#68's written investigation statement in response to these allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment, breakfast was not ready at the time, puffer call light attached to bed by maintenance and cannot come off the bed. EMS must have seen roommates call light. SW #68 did not substantiate these allegations. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed the Veterans Administration Medical Center (VAMC) has a contract with an ambulance service (name of local ambulance service) to transport all residents that are veterans, to any of their appointments. The VAMC is responsible for setting up and paying transport for any appointment no matter where it is. When asked what the process was to assure residents get to their appointments, Staff#5 explained the contact person at the VAMC calls at least once a month, and goes over all appointments residents who are veterans have, where the appointments are, and tells me what time the ambulance is to pick up the resident. Staff#5 said she writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had appointments four (4) different days in December. The appointments noted on 12/26/17, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. Staff#5 said the VAMC always uses the same ambulance service for transports. When asked if the ambulance service ever is late or comes early, the receptionist replied, The ambulance service (the name of) is real good about being right on time. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility investigation resulted in the allegations being unsubstantiated, however the investigation did not appear to be thorough. The facility's appointment calendar, clearly documented the ambulance was to pick the resident up at 7:00 AM to transport the resident for 7:30 AM labs, and that there was a second appointment at 9:00 AM. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. There was no evidence the resident needed to be fasting for his lab tests, nor any evidence that any breakfast had been offered to the resident, or any arrangements made to provide him a breakfast or snack. The resident did not get On 02/06/18 at 10:15 AM, after multiple failed attempts for observations and interview with Resident #92 due to not finding him in his room or elsewhere in the facility, an interview with the Administrator revealed Resident #92 was transferred to Veterans Administration Medical Center (VAMC) yesterday, 02/05/18. Administrator said this was a plan discharge that the resident had been on a waiting list to become a resident at the VAMC's facility, and an opening came available yesterday evening. Interview with the Coordinator of Health Information Management (HIMC Staff#73), on 02/07/16 at 10:00 AM, revealed Resident #92 had said he wanted to transfer to a facility closer to his ex-girlfriend so she could visit him. HIMC Staff#73 said the girlfriend told him there was one close to her that the Veterans Administration (VA) would pay for. HIMC Staff#73 said, the facility told him multiple times there was not one in that area the girlfriend was referring to, but he did not believe them, and would get upset about it each time. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she reported the situation because she is a mandatory reporter. VAMC SW#302 said, I was concerned for the resident because of his recent [DIAGNOSES REDACTED]. VAMC SW#302 said she reported to all the appropriate agencies, and spoke by phone to the facility's Director of Nursing (Nurse Executive Director) and SW #68 concerning these allegations on 12/26/17. VAMC SW#302 said she first saw the resident, on 12/26/17, after first being asked to see him, by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. The resident was alert and oriented and was asking to go to another nursing home closer to his family. The resident said the nursing home he lived at did not beat him, but they don't take care of him. The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew said his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. Review of VAMC SW#302 Notes dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived he was not cleaned up. His call bell was across the room where he could not reach it. He had no breakfast. We had to ask someone to empty his catheter bag. When staff emptied the bag they did not look under the covers to check to see if anything else needed taken care of. Further review of records (facility and VAMC records) revealed alternate placement was discussed with the resident several times. The resident had discussed moving to a nursing home closer to his family and girlfriend. When the resident discovered there was not another nursing home the Veterans Administration was contracted to pay for in the area close to his family and girlfriend, Resident #92 did not want to personally pay and choose to return to the facility. The Ombudsman was interviewed via phone, on 02/08/18 at 2:30 PM, for concerns regarding these allegations. Interview with Ombudsman revealed during her interview at the facility with Resident #92 and facility staff, on 01/03/18, the resident said he lied about his head being stuck in the bed rails, that he lied just because he was mad. The Ombudsman said Resident #92 bragged on the care he receives at the facility, appeared [MEDICATION NAME] pleased, and had no complaints against the facility. After record review, abuse and neglect policy review, staff interview, VAMC staff interview, and review of the facility's investigation record, the evidence revealed some of the allegations were substantiated. There is not enough evidence to substantiate the allegation the resident's special blow call light was not in reach of the resident. The resident denied, in front of multiple witnesses, his head was hitting the side rail on his bed, and someone shut the door without providing any care. The resident said he falsely made these accusations because he was mad. The facility did neglect to ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The resident did not have breakfast, and the facility did not provide or make any arrangements for the resident to have breakfast or a snack on a day the resident was scheduled to be out of the facility for medical appointments. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. b) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. | 2020-09-01 |
| 2 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 656 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and Center (VAMC) staff interviews, the facility did not implement interventions in Resident #92's care plan to meet the resident's preferences and address the resident's medical, physical, mental and psychosocial needs. This pertained to the care area of activities of daily living (ADL), concerning shaving Resident #92 daily. This was true for one (1) of three (3) care plans reviewed for resident's totally dependent for ADL care. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Observations, on 02/05/18 at 11:55 AM., revealed Resident #92 appeared clean, without any body odors, Foley catheter was draining to drainage bag on bedside. The resident was lying in his bed, eyes closed with hair stubble noted on resident's chin. The resident has a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands, and it was within reach of the resident. On 02/06/18 at 9:05 AM, review of grievance and concerns revealed on 09/12/17 the resident complained . he was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face, . Resolution to these concerns were completed by 09/27/17 with staff being educated to shave resident daily, Kardex being updated with the resident's preferences. A Kardex provides specific instructions, for the nursing assistants, concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed under the skin care focus instructions written as is ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. On 02/08/18 11:03 a.m., an interview with VAMC SW#302 revealed she reported a situation concerning Resident #92 because she is a mandatory reporter and had notified the facility of the allegations. VAMC SW#302 said she first saw the resident, on 12/26/17, after being asked by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304 to see the resident. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 described the resident was alert and oriented and the ambulance crew told VAMC SW#302, the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew told VAMC SW#302 his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. | 2020-09-01 |
| 3 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 657 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility did not revise a care plan to meet the resident's medical, physical, mental and psychosocial needs. Resident #92's care plan was not revised with resident specific interventions to address the resident's newly diagnosed fractured neck. This was true for one (1) of three (3) care plans reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Facility census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the cervical collar. When asked where the physician's orders [REDACTED]. RN#49 requested the Coordinator Health Information Management, Staff#73, to try and locate the order. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. Review of Resident#92's care plan with RN#49 revealed there were no resident specific interventions to address the resident's current care needs related to the new [DIAGNOSES REDACTED]. On 02/07/18 at 12:50 PM, review of medical records revealed resident was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility with a soft cervical collar | 2020-09-01 |
| 4 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 677 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, facility staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to ensure Resident #92 received the care and services regarding an aspect of his life in the facility which was significant to the resident regarding bathing and shaving, and did not receive proper grooming when going to appointments outside the facility. This was true for one (1) of eleven (11) sample residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. b) Grooming for appointments outside the facility On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. Review of the facility's investigation findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The facility did not ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. Social worker SW#68's written investigation statement in response to the allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment ., however the facility's appointment calendar book for the month of (MONTH) (YEAR) showed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed when a resident has an appointment Staff#5 writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. Review of VAMC SW#302 progress note, dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived, he was not cleaned up . We had to ask someone to empty his catheter bag. When staff emptied the bag, they did not look under the covers to check to see if anything else needed taken care of. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she first saw the resident (Resident#92), on 12/26/17, after first being asked to see him by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 said, The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up . The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. | 2020-09-01 |
| 5 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 684 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide a resident with the necessary care and services to maintain the highest practicable level of well-being for one (1) of three (3) sample resident reviewed for neglect during a complaint investigation. The facility failed to obtain a physician's orders [REDACTED].#92, after being diagnosed with [REDACTED]. Resident identifier: #92. Facility census: 107. Findings include: a) Resident #92 On 02/05/18 at 12:48 PM, review of records revealed Resident #92, a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder, totally dependent for all care, was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility and with a soft cervical collar. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the soft cervical collar. When asked where the physician's orders [REDACTED].#49 after reviewing the record, said she could not find an order. RN#49 agreed a follow up for orders for the resident's current care needs due to the new [DIAGNOSES REDACTED].#49 requested the Coordinator Health Information Management, Staff#73, to try and locate a order for the soft cervical collar. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. | 2020-09-01 |
| 6 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 164 | D | 0 | 1 | ELSQ11 | Based on random observation and staff interview the facility failed to ensure the personal privacy and confidentiality of a resident's medication records. Resident identifier: #82. Facility census: 116. Findings include: a) Resident #82 On 05/18/17 at 6:30 a.m., Licensed Practical Nurse (LPN) #55 left Resident #82's medication record open in a way the information could be read by a person other than the nurse passing the medications. The LPN entered the resident's room and returned to the cart on at least two (2) occasions and continued to leave the medication information exposed. At 6:33 a.m. on 05/18/17, LPN #55 agreed the information was exposed. | 2020-09-01 |
| 7 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 241 | E | 0 | 1 | ELSQ11 | Based on observation and staff interview, the facility failed to maintain residents' dignity during the dining experience for seven (7) of twenty-seven (27) residents in the main dining room. A random observation revealed obviously soiled linens were not changed in a timely fashion for Resident #25. Facility census: 116. Resident identifiers: Resident #25, #124, #77, #71, #21, #49, #192 and #68. Findings include: a) Resident #25 During a random observation on 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 placed a sheet over Resident #25's blanket. Observation revealed a brown stain covering an area of approximately two feet by two feet (2 ft x 2 ft). The nurse aide looked at the area and verbalized, Oh, Lord. Another observation at 9:20 a.m., revealed Resident #25 sitting at the bedside eating his breakfast. The stained blanket was again visible from the doorway. Upon request, the Center Nurse Executive (CNE) completed an observation and interview. Resident #25, interviewed at 9:22 a.m., said he was sitting at his bedside the night before and had spilled his coffee, making a big mess. The resident said the accident occurred about 10:00 p.m. on 05/16/16. At 9:24 a.m., the CNE acknowledged the blanket should have been changed at the time of the spill, and as the resident sat at the bedside for breakfast, staff had additional opportunity to change the blanket. b) Residents #124, #77, #71, #21, #49, #192, and #68. A dining observation on 05/16/17 from 11:10 a.m. and 12:45 p.m., revealed Residents #124, #77, and #21 sat in the dining room and did not converse with other residents or staff during the pre-meal interim or during mealtime. Staff asked residents meal preferences, but did not converse in a social manner. Resident #71, sat at a table alone. She verbalized she had no friends, and felt lonely. At another table, Resident #21 did not have a tablemate. She looked around the room at other residents, but neither staff nor residents spoke to her throughout the course of the dining experience. Resident #77 and #125 required assistance to eat, but staff did not interact with the residents in a social manner. Residents #49 and#192 were seated at the same table. Resident #192 was served at 12:11 p.m., but Resident #49 did not receive his tray until 12:19 p.m. Staff began serving the long table nearest the kitchen at 12:02 p.m. At 12:08 p.m., Resident #68 verbalized in a crying tone, I can't (cannot) wait much longer. At that time, tablemates called out to the administrator who was standing nearby. The resident, with a frowned expression, informed her she had only ordered soup and did not understand why she had not received it. An observation and interview with the clinical nurse educator (CNE), toward the end of the meal, at about 12:30 p.m. on 05/16/17, agreed staff did not interact socially with residents who did not have a tablemate or who were not socializing with others. The CNE verbalized some residents were capable of socializing, but acknowledged staff should have interacted with them on a social level. | 2020-09-01 |
| 8 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 253 | E | 1 | 1 | ELSQ11 | > Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services necessary to maintain a comfortable and sanitary interior. This was evident for fifteen (15) of thirty-four (34) rooms observed during Stage I of the Quality Indicator Survey. Cosmetic imperfections or items in need of repair and/or cleaning in resident rooms included discolorations of the toilet bowl jets, debris noted on the floor for prolonged period of time, window sills and/or window blinds dirty/dusty in need of cleaning, a sliding curtain type bathroom door with a black-colored substance on the bottom portion, caulk missing around a toilet base, veneer missing from a bathroom door with the wood or particle board beneath it visible, cove base pulled away from the wall in a bathroom, the inside of a wall heating unit had a dirty vent with loose debris, and a piece of wallpaper not adhered to a wall. Affected rooms included room #101, #102, #103, #104, #105, #106, #111, #118, #126, #128, #129, #134, #141, #142, and #163. Facility census: 116. Findings include: a) Stage I findings During Stage I of the Quality Indicator Survey on 05/15/17 and on 05/16/17, thirty-four (34) resident rooms were observed. Of that number, fifteen (15) rooms were found with concerns related to maintenance and/or housekeeping issues. The identified rooms were toured with Housekeeping Manager (HM) #83 on 05/17/17 between 3:00 p.m. and 3:30 p.m., and with Maintenance Supervisor (MS) #88 between 3:30 p.m. and 3:45 p.m. Identified concerns were: - Room 101 The water jets in the toilet looked dirty. During a tour on 05/17/17, HM #83 said they had been using a type of acid-base cleanser to try to remove the discoloration as other products have not worked as well. A small piece of tissue lay on the floor at the head of the bed next to the window. Beneath that bed was what looked like a broken piece of hard, white colored vinyl. These objects were first observed on the floor on 05/16/17 at 11:14 a.m. On 05/17/17 at approximately 3:00 p.m., HM #83 removed the tissue from the floor and the broken piece of vinyl from beneath the bed. She said it was a broken piece off a coat hanger. - Room 102 On 05/17/17 during the afternoon tour, HM #83 agreed that the toilet bowl jets looked dirty, and the window blind was dusty and the window sill dirty. She said she thought perhaps some sheetrock fell on to the window sill. She said housekeeping staff would attend to those issues. - Room 103 During the afternoon tour on 05/17/17, HM #83 agreed the window blind was dusty and needed cleaned. There was a pile several inches thick of an unknown substance that resembled bird seed in the right lower corner of the window sill. HM #88 did not know the origin of that substance or what it was, but said they would clean it right away. - Room 104 On 05/17/17 during the afternoon tour, HM #83 agreed the window blinds were dusty and needed cleaned. Also, behind the bed by the window lay a silver hair barrette next to the cove base which was first observed on 05/16/17 at 11:32 a.m. About a foot away was a bunch of food particles that went up to the cove base behind the first bed by the door. The food particles were first observed on 05/16/17 at 11:32 a.m. HM #83 said she would speak to housekeeping staff about more thorough sweeping of the rooms. - Room 105 During the afternoon tour on 05/17/17, HM #83 agreed that the outside of the window sill was dirty and needed cleaned, and that the water jets in the toilet bowl looked dirty. - Room 106 On 05/17/17 during the afternoon tour, HM #83 agreed that the window blinds were dusty and needed cleaned, and that the water jets in the toilet bowl needed cleaned. - Room 111 Observations during Stage I of the survey on 05/15/17 at 3:24 p.m. noted the privacy curtain had some soiled areas. During the afternoon tour on 05/17/17, the privacy curtain was clean. - Room 118 During Stage I of the survey on 05/16/17 at 11:28 a.m., the privacy drape had areas where it was dirty. The privacy curtain was found to be clean on 05/17/17 during the afternoon tour. HM #83 agreed the window blinds were dusty and needed cleaned. - Room 126 On 05/17/17 during the afternoon tour, MS #88 agreed the sliding curtain type of bathroom door was soiled with a black mold-like substance on the bottom portion of the curtain. He said the curtain would have to be replaced as there was no way to adequately clean it. Also, during Stage I of the survey on 05/15/17 at 2:41 p.m., the floor was littered with two caps for gastrostomy tube syringes, a blue cap, and a lipstick tube cap. Those items were no longer present during the afternoon tour on 05/17/17. - Room 128 At approximately 3:30 p.m. on 05/17/17, MS #88 agreed the caulk on the front section of the commode base was missing. He said he would repair it right away. - Room 129 At approximately 3:35 p.m. on 05/17/17, MS #88 agreed some veneer was missing from the front of the bathroom door, which allowed the wood or particle board beneath to show through. He said he would repair this right away. - Room 134 At approximately 3:40 p.m. on 05/17/17, MS #88 agreed that a section of cove base or molding had pulled away from the wall on the left side of the wall behind the bathroom door. He said he would repair this right away. He also agreed that there was dirt in the corner behind the entrance room door where it had not been cleaned in that section. - Room 141 During the afternoon tour on 05/17/17 with HM #83, she agreed that the window sill was dirty and the blinds dusty. - Room 142 On 05/1717 during the afternoon tour, HM #83 agreed that the window blinds were dusty and needed cleaned. - Room 163 During the afternoon tour on 05/1717, MS #88 agreed the vent on the inside of the room's heating/cooling unit was dirty with loose debris. He said maintenance took care of the inside of the units, and he would make sure it was cleaned. Also, a small section of wallpaper inside the room near the floor in one area was not adhering to the wall and was loose. MS #88 said that would be corrected right away. b) During a pre-exit interview with the administrator on 06/01/17, at approximately 7:00 p.m., it was discussed that maintenance and housekeeping had toured on 05/17/17 and all the environmental findings were discussed during an afternoon tour between 3:00 p.m. and 3:45 p.m. with HM #83 and MS#88. The administrator acknowledged her awareness of the environmental tour on that date. | 2020-09-01 |
| 9 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 278 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate quarterly minimum data set (MDS) assessment to reflect the resident's pain medication regimen. This was true for one (1) of thirty-two (32) residents reviewed. Resident identifier: #100. Facility census: 116. Findings include: a) Resident #100 Review of Resident #100's medical records revealed a physician's orders [REDACTED]. Record review revealed Resident #100 continued to receive this medication through the month of (MONTH) (YEAR). Review of a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/05/17, revealed Resident #100 did not receive scheduled pain medication. On 06/01/17 at 5:46 p.m., the MDS coordinator, Registered Nurse (RN) #108, agreed the quarterly MDS with an ARD of 05/05/17 should have been coded to identify Resident #100 received scheduled pain medication. | 2020-09-01 |
| 10 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 279 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and family interview, the facility failed to develop a care plan for a resident with bruises and a skin tear (#92), failed to establish measurable objectives to monitor a resident's progress related to activities (#143) and range of motion (ROM) (#43), and failed to develop a care plan timely related to assessing a thrill and bruit for a resident with an arteriovenous graft (#45). Four (4) of thirty-two (32) residents on the sample were affected. Facility census: 116. Resident identifiers: #143, #92, #45, and #43. Findings include: a) Resident #143 The resident's medical record included a Brief Interview for Mental Status (BIMS) on which the resident scored ten (10), indicating moderate cognitive impairment. During a Stage 1 interview on 05/16/17 at 2:12 p.m., a family member verbalized Resident #143 liked to attend Church services. Resident #143, interviewed on 05/31/17 at 1:56 a.m., exhibited symptoms of confusion related to time, but with inquiry, verbalized she liked to go to church and wanted to go every Sunday. The resident expressed she did not care what denomination it was, just Christian. The care plan noted Resident #143 would indicate satisfaction in daily routine/activities as evidenced by verbalizing satisfaction, increase in affect during participation, increased focus and attention to activities of choice. The interventions included to assist, as needed, to activities of interest church, parties, socials, crafts, pets, music, and reading. During review of the resident's care plan with the administrator on 05/31/17 at 6:12 p.m., when asked how the facility measured increased affect, focus and attention, the administrator acknowledged the goal was not measurable, shook her head in a yes motion, and said, I get you. b) Resident #92 An observation on 5/16/17 at 1:08 p.m., revealed bluish red bruised from Resident #92's hand to upper arm. A bandage was present on the left forearm, and the resident verbalized he had obtained a skin tear. During a wound care observation, on 05/23/17 at 11:40 a.m., the nurse removed a bandage from the resident's left great toe, revealing an open wound on the top of the toe. A physician's orders [REDACTED]. The care plan, reviewed on 05/24/17, revealed no evidence of bruising or of the toe wound. MDS Coordinator #108, interviewed at 2:01 p.m., voiced the nurses updated the care plans as new orders, concerns arose. She reviewed the care plan and verified a care plan was not developed related to the bruises or the skin tear on Resident #92's toe. c) Resident #45 Review of medical records revealed Resident #45 had an Arteriovenous Fistula (AV) for [MEDICAL TREATMENT] treatments. Review of the physician's orders [REDACTED]. The resident continued to have an AV fistula site at the time of the current survey beginning 05/15/17. Review of the resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no evidence the facility monitored the resident's AV fistula after 11/22/16 until a new order written on 05/02/17. On 05/24/17 at 4:21 p.m., Registered Nurse (RN) #126 stated the resident had had an AV fistula site for [MEDICAL TREATMENT] for at least three (3) years. Review of an article Caring for a patient's vascular access for [MEDICAL TREATMENT] in the 2010 Lippincott[NAME] & Wilkins medical surgery text book found it included a nurse should check the AV fistula site for patency at least every eight hours. On 05/24/17 at 3:18 p.m., the facility administrator agreed monitoring the bruit and thrill was not routinely completed, nor did the care plan include monitoring the AV fistula from 11/22/16 until 05/02/17. d) Resident #43 Review of the resident's medical record on 05/22/17 found the resident had [DIAGNOSES REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 03/17/17, assessed contractures of the right upper extremity. Review of the care plan found it contained a focus where it identified her right side extremities were weaker than the left. The care plan identified that she had contractures of the right shoulder, elbow, wrist and hand; however, the care plan failed to provide individualized and measurable goals they wished to achieve related to the right upper extremity contractures. The care plan failed to provide individualized interventions to help prevent further loss of range of motion and/or other negative outcomes, related to the right upper extremity contractures. The care plan contained no directives for range of motion or for any splint/orthotic devices. During an interview on 05/22/17 at 4:01 p.m., Director of Rehabilitation Services #52, said (MONTH) (YEAR) was the last time occupational therapy (OT) had her on its case load. Their goals were for passive and active range of motion to the right upper extremities for three (3) sets of ten (10) repetitions daily to establish a contracture management program. Their goal was for her to work up to tolerate a right hand orthotic for four (4) hours per day. The final long term goal was to discharge her to the restorative program with 100% staff training for contracture management program. She said the director of nursing (DON) was the head of the restorative nursing department. In an interview on 05/22/17 at 4:22 p.m., the director of nursing (DON) said this resident used to have a Posey roll, and she used to have restorative nursing services for range of motion with restorative aides; however, she no longer received restorative services. She said she felt the regular nursing assistants on the units did enough range of motion during activities of daily living to make it count for range of motion. She said that the resident had a Posey roll for her right hand prior to a week-long hospital stay the first week in (MONTH) (YEAR), but it had not been re-ordered since the (MONTH) hospitalization . She said most likely restorative services order fell through the cracks and was not re-ordered upon her (MONTH) return to the facility. The DON provided a copy of the resident's care plan on 05/22/17 at 4:45 p.m. When asked to provide any evidence of care planned individualized and measurable goals and interventions related to contracture management, no further evidence was provided. Observation and interview with the resident on 05/23/17 at 9:41 a.m. found she could use her left hand and try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three middle fingers on the right hand were contracted, and she could not stretch them out with her left hand. Those three fingers were bent downward, and then pointed back toward the wrist. She wore no splint device or palm protector when observed in Stage I of the Quality Indicator Survey. | 2020-09-01 |
| 11 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 280 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked 150 feet two (2) times a day. Additionally, the physician's orders [REDACTED]. An interview with the director of nursing, immediately following the interview with NA #23, confirmed the care plan intervention had not been revised to reflect the physician's orders [REDACTED].> c) Resident #115 Medical record review on 05/30/17 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. According to the medical record, she experienced actual falls on 04/30/17, 05/03/17, and 05/12/17. On the first and second occurrence she was found lying on the floor by the bed. On the latter occurrence, she slipped out of the wheelchair and onto the floor. Review of the current care plan found this resident was care planned as at risk for falls. The care plan was silent for any revisions showing the resident was not only at risk for falls, but that she had sustained actual falls since coming to the facility. In an interview with minimum data set (MDS) Registered Nurse #68 on 05/31/17 at 10:39 a.m., she reviewed the care plan and said they did not revise care plans to include the actual falls a resident experiences. When interviewed on 05/31/17 at 10:50 a.m., the administrator acknowledged that the care plan was not revised to include that she had sustained actual falls since admission to the facility. She said they typically update new interventions they may have added after a fall, but they do not revise the care plan to include either that the resident had sustained actual falls, or the dates of the falls. | 2020-09-01 |
| 12 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 282 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, visitor/family interview, staff interview, observation, and policy review, the facility failed to ensure services were provided according to the resident's written plan of care for five (5) of thirty-two (32) Stage 2 residents. Residents #27 and #141 did not receive planned restorative services. Resident #143 did not participate in activities as identied on her care plan. Resident #163 did not receive treatments in accordance with the plan of care, and Resident #124 did not receive foods in accordance with her plan of care. Facility census: 116. Resident identifiers: Resident #27, #143, #141, #163 and #124. Findings include: a) Resident #27 A medical record review related to accidents revealed a physician's orders [REDACTED].#27 required limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant that Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. The restorative nursing for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at about 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. b) Resident #143 A Stage 1 family interview, on 05/16/17 at 1:58 a.m., revealed Resident #143 preferred church activities. The family member said the resident liked to attend church services and went every Sunday morning. The minimum data set (MDS) with an assessment reference date (ARD) of 05/05/17 noted a brief interview for mental status (BIMS) score of ten (10) which indicated moderate cognitive impairment. The preferences for customary and activity section noted it was important for the resident to receive a snack between meals, music, reading, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. The recreation assessment noted the resident enjoyed small groups. The resident's care plan indicated Resident #143 enjoyed being in the dining room for lunch and socializing with staff. A nursing assessment dated [DATE] noted the resident watched television (TV) and attended church on occasion. The recreation assessment noted the resident seemed to enjoy games and religious activities. Observations on 05/15/17 at 1:46 p.m., 05/16/17 at 8:28 a.m., 05/31/17 at 10:04 a.m., revealed no evidence of participation in activities. Nurse Aide (NA) #73, interviewed on 05/31/17 at 10:23 a.m., said she was not sure what Resident #143 liked as she usually always worked on the south hallway. NA #100, interviewed at 10:24 a.m., said she had not really worked the hallway too long, and was not sure what the resident liked to do. The NA verbalized the resident did not come out of the room much and wanted staff to leave her alone. The (MONTH) (YEAR) recreation log indicated Resident #143 participated with socialization daily, attended a special event on one occasion (05/24/17), hydration cart two (2) of 28 opportunities,and participated with reminiscence daily. It noted she attended church on four (4) of seven (7) opportunities, Bible study two (2) of four (4) opportunities, and gospel music two (2) of five (5) opportunities. Recreation Assistant (RA) #34, interviewed on 05/31/17 at 1:33 p.m., said church services were usually in the morning and Bible study in the evenings. The RA reviewed the calendar and said the facility did have church services every Sunday morning and of four (4) opportunities, no evidence was present to indicate Resident #143 had been invited to two (2) of them. Upon inquiry, the RA said the floor staff were not provided information as to whom should attend each event. During an interview and observation on 05/31/17 at 1:56 p.m., Resident #143 was eating lunch in her room. She said she had lasagna for lunch (one small piece of pasta remained on her plate) and they put too much mayo (mayonnaise) on the salad. She exhibited confusion as to person and place, and talked about her mother. When asked what time she would like to get up she said around eight o'clock (8:00 a.m.). Upon inquiry as to what activities she liked, Resident #143 said she went to church every Sunday. The resident said she did not care what denomination it was, just Christian. On 05/31/17 from 4:37 p.m., until 4:59 p.m., during a dining observation, Resident #143 sat at a table with two (2) other residents. She was seated at the corner of the table, attempting to eat a sandwich with a spoon. The residents did not interact. RA #34, NA #116, RA #22, NA #79, Bookkeeper #20, and Activity Director/Guest Services #36 assisted in the dining room. No one conversed with the resident. RA #34 verbalized the social activity in which Resident #143 participated daily at 4:30 p.m., was the pre-meal activity. Upon inquiry, the recreation assistant verbalized Resident #143 would be included as having participated in the activity, even though no one socially interacted with the resident. The activity log and observations were reviewed with administrator on 05/31/17 at 6:12 p.m. She acknowledged the noted lack of participation related to the number of opportunities for things which were important to Resident #143. Additionally, she verbalized acknowledgement related to lack of socialization for the dining event and concurred the resident did not receive activities in accordance with the plan of care. c) Resident #141 During a Stage 1 interview, on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. The medical record revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141, on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #34, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. An interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17 and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17 or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17 and 04/28/17. Resident was out of facility for one (1) date and refused (R) for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. d) Resident #163 A medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) # --- revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. Upon inquiry as to whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40)opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. e) Resident #124 The medical record was reviewed on 06/01/17. [DIAGNOSES REDACTED]. She weighed only 82 pounds on 05/26/17, as recorded on the computer weight records. Medications ordered included [MEDICATION NAME] fifteen (15) milligrams daily to help increase her appetite. Review of the current comprehensive care plan included interventions for weight maintenance or gain for this edentulous resident on pages twenty-one (21) and twenty-two (22) of the care plan. Interventions included eight (8) ounces of buttermilk with meals three (3) times per day at her request, and ice cream with lunch and dinner. She was observed eating her evening meal on 06/01/17 at 5:25 p.m. She had no buttermilk. Rather, dietary sent her a carton of skim milk. Dietary sent her a small bowl covered with cellophane wrap that looked like pudding. When asked if that was ice cream, the resident replied in the negative. When asked if she liked buttermilk with her meals, she replied in the affirmative. Nursing Assistant (NA) #11 was in the room at the time, assisting the resident's room-mate with her tray. NA #11 asked the resident if she would like some buttermilk, and the resident replied I sure would! NA #11 said she would also get her some ice cream from the dietary kitchen. An interview was conducted with the dietary director #89 on 06/01/17 at 5:50 p.m. Upon inquiry as to whether he received dietary orders for this resident to have eight (8) ounces of buttermilk with each meal, and ice cream with lunch and dinner, he slightly thumbed through some half sheets of dietary orders and diet changes he kept in a folder. He said he would have to check his file to see if he received an order for [REDACTED]. On 06/01/17 at 7:05 an interview was conducted with the director of nursing and the administrator. The administrator said the dietary director sent the buttermilk tonight after surveyor intervention. The administrator said the dietary director found he had ice cream, and sent ice cream to the resident this evening after we had discussed it. She agreed that the care plan directed this resident to receive eight (8) ounces of buttermilk with each meal, and ice cream daily with each lunch and dinner meal. | 2020-09-01 |
| 13 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 309 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure eight (8) of thirty-two (32) Stage 2 residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility did not assess and monitor a resident's pain, did not ensure implementation of physician's orders [REDACTED].#163). Staff failed to properly position residents during meals and/or in bed (#76 and #101), did not ensure monitoring of residents receiving [MEDICAL TREATMENT] (#159 and #45), did not obtain neuro checks after a fall (#59), and did not follow physician's orders [REDACTED].#59). For Resident #100, the facility failed to monitor the resident's [MEDICATION NAME] as ordered and failed to provide physician ordered foods to Resident #124. Additionally, the facility failed to follow orders for restorative ambulation for and assessment of a pulse rate prior to administration of a medication. Additionally, the facility failed to follow physician's orders [REDACTED].#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141). Facility census: 116. Findings include: a) Resident #163 1. Medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) #72, revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. When asked whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed as ordered for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml, administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17 and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). The facility's pain management policy, reviewed on 05/23/17 at 9:00 a.m., required a pain evaluation be completed in the resident had a change in pain status. Residents receiving interventions for pain would be monitored for the effectiveness and side effects. On 05/22/17 at 2:57 p.m., the electronic medical record and paper medical record, reviewed with the CNE, confirmed no information was present to indicate the change in condition, or need for increased use of pain medication. The CNE agreed the change in the order was not a clarification and should have been discontinued, or noted as an error. The initial order indicated [MEDICATION NAME] sulfate 20 milligrams per milliliter (mg/ml) administer 0.75 ml sl every hour as needed and clarified to be administer 0.5 ml sl every hour as needed. 3. The bowel movement monitoring assessment indicated Resident #163 had no bowel movement on 05/01/17, 05/02/17 and received milk of magnesia (MOM) with no results noted until 05/04/17. No follow-up was noted on 05/03/17. No bowel movement was noted for 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, and 05/17/17. The action taken indicated MOM was administered on 05/14/17 with no results and no follow-up to ensure the resident had a bowel movement. Additionally, no information was present to indicate the facility had assessed and monitored the resident for complications. On 05/22/2017 at 4:15 p.m., Resident #163's medical record was reviewed with the interim CNE related to omission of data for bowel movements, not following physician's orders [REDACTED]. The CNE acknowledged the facility failed to assess/reassess Resident #163's pain and/or constipation per physician's orders [REDACTED]. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. b) Resident #159 A medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident was in the hospital on [DATE] and the resident was readmitted to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. [MEDICAL TREATMENT] communication records, reviewed from 12/15/16 to present revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for a facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records included 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., an inquiry as to the facilit's responsibility related to the permacath and graft site, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, (MONTH) and (MONTH) (YEAR). c) Resident #101 A Stage 1 observation on 05/15/17 at 1:27 p.m., revealed Resident #101 in bed, leaning to the right side against the siderail. No support devices were in place to assist with maintaining an upright position. The bedsheets were tucked tightly over her toes holding the feet in plantar flexion position. On 06/01/17 at 11:19 a.m., a Stage 2 observation revealed the resident leaning against the side rail. The head of the bed was elevated between 45 and 90 degrees. Resident #101 verbalized she slid to the side, did not like lying that way, and would like to sit up. She had no positioning devices in place to maintain upright positioning. When asked if she could reposition herself, the resident reached back in an attempt to grab the siderail, but could not reach it. A Nurse Aide (NA) entered the room at that time and said she would assist the resident into a comfortable position. Physical Therapy Assistant (PTA) #52 and Physical Therapist #104, interviewed on 06/01/17 at 3:56 p.m., said Resident #101 was currently on the occupational therapy (OT) case load for wheelchair (w/c) positioning. Upon inquiry as to how the facility identified the need for therapy, the OT verbalized the resident was picked up on 05/23/17, during a routine screen by therapy. The OT said the resident had a spinal cord injury and was hoping for neuro-recovery and strength. The care plan indicated Resident #101 required assistive devices for bed mobility and limited to extensive assistance of one (1) person. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 04/18/17 indicated Resident #101 required extensive assistance for bed mobility. d) Resident #76 The medical record review yielded a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17. It noted Resident #76 required extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides, upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m., revealed Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m. the resident was in bed, lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 had slid down in his bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Upon inquiry, LPN #62 confirmed he was not positioned correctly and needed pulled up in bed. She asked the NA to assist her to position him correctly to eat his meal. e) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. f) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. g) Residents #101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days | 2020-09-01 |
| 14 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 312 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming for two (2) of thirty-two (32) sampled residents. Resident #117 had unshaven facial hair. Resident #76 had long unkempt hair, was unshaven, and wore the same clothing on successive days. Resident identifiers: #117 and #76. Facility census: 116. Findings include: a) Resident #117 Observation on 05/16/17 at 2:16 p.m. found this [AGE] year old resident had numerous long white hairs on her chin and lower jaw area. On 05/23/17, review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 04/13/17, found her Brief Interview for Mental Status (BIMS) score was three (3), indicating severe cognitive impairment. She required limited assistance with personal hygiene. Review of the resident's care plan found a focus statement identifying she was at risk for decreased ability to perform activities of daily living (ADL) functions due to generalized weakness, fluctuation in cognition/dementia with behaviors, and multiple other disease processes. Interventions included to provide assistance as needed, as the ADLs might fluctuate. Observation on 05/23/17 at 12:45 p.m. found she still had long white hairs on her chin and lower jaw area. When asked about the resident's chin whiskers, Nurse Aide (NA) #59 replied that just this morning he commented that the resident's beard was longer than his. He said he would shave her right away, and he did. During an interview on 05/23/17 at 4:20 p.m., the administrator said this resident's ADL abilities fluctuated due to her behaviors and dementia. No further information was provided about the resident's facial hair. b) Resident #76 A Stage 1 observation on 05/15/17 at 1:47 p.m., revealed Resident #76 was unshaven, and his hair was long, uncombed and unclean. Another observation on 05/16/17 at 8:30 a.m., revealed his beard growth remained unshaved. On 05/17/17 at 3:24 p.m., the resident's hair remained long and disheveled, but he had been shaved. The nurse said the hospice aide had provided care. An observation on 05/23/2017 at 9:09 a.m., found Resident #76 in bed awake, watching a game show on his roommate's television. The fingernails on his right hand had dark brown debris beneath them. His hair was uncombed, and he had not been shaved. When asked how often he would like to be shaved, he replied he would like shaved right now. The resident voiced he preferred to be shaved daily. At 11:56 a.m., the resident had been shaved, and his hair combed. Another observation at 2:25 p.m. revealed his nails had been clipped and cleaned. Nurse Aide (NA) #135, on 05/23/17 at 2:28 p.m., said the resident had gotten weak and now staff did most of his care. She verbalized the hospice aide had provided his care this date. The minimum data set (MDS) with an assessment reference date (ARD) of 05/15/15 indicated Resident #76 required extensive assistance with dressing, eating, toilet use and personal hygiene. The assessment indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. The care plan, revised on 05/10/17, noted Resident #76 required assistance with activities of daily living (ADLs) with a goal to improve current level of ADL functions by next review. A hospice nurse aide (NA) provided care two (2) times a week. Licensed Practical Nurse (LPN) #62, interviewed on 05/24/17 at 1:26 p.m., said the resident was very noncompliant, but most of the time would let staff provide care if asked. She said the nurse would re-direct him if he refused for the nurse aides. An observation with the interim clinical nurse educator (CNE) on 05/24/17 at 4:10 p.m., revealed Resident #76 was still wearing the same clothing placed on him by the hospice NA on 05/23/17. During an observation on 06/01/17 at 11:27 a.m., Resident #76 was sitting in the dining room for lunch. His hair had been cut and he was clean shaven. The resident said he preferred his hair cut short. During a discussion with the CNE on 06/01/17 at 6:30 p.m., she said the facility was responsible to care for the resident on the days the hospice aide did not come to the facility. She voiced the resident had a decline, was dependent upon staff for care, and the resident should have been shaved by the facility nurse aides on the days a hospice staff member was not in the building. | 2020-09-01 |
| 15 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 315 | D | 0 | 1 | ELSQ11 | Based on a random observation and staff interview, the facility failed to provide care in a manner to prevent urinary tract infections. A staff member placed washcloths in the bathroom sink basin in preparation for incontinence care, creating a potential for introducing potential pathogens into the resident's urinary tract. This practice affected one (1) resident for whom incontinence care was observed. Facility census: 116. Resident identifier: #163. Findings include: a) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Licensed Practical Nurse unfastened the resident's brief revealing the resident had had an incontinence episode. Nurse Aide (NA) #102 obtained a stack of washcloths, placed them in the bathroom sink basin, and turned on the water. The NA wrung the washcloths and laid them on the left side of the sink near the faucet handle. NA #102 dried her hands, picked up the washcloths and gave them to Licensed Practical Nurse (LPN) #72 who utilized them to perform peri-care. | 2020-09-01 |
| 16 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 318 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion received services to help prevent further decline. Resident #43 had contractures of the right hand, wrist, elbow, and shoulder, but had no range of motion or orthotics ordered to help prevent further decline or other negative outcomes. Resident identifier: #43. Facility census: 116. Findings include: a) Resident #43 Review of the resident's medical record on [DATE] found the resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], found she came to the facility with contractures of the right hand, wrist, elbow, and shoulder. Review of the most recent comprehensive assessment with an ARD of [DATE], found she was assessed with [REDACTED]. The facility assessed her as having received no therapy services, no restorative nursing services, and no hand or wrist splint/orthotic device during the look back period. Her Brief Interview for Mental Status (BIMS) score was eleven (11), indicating moderately impaired cognitive functioning. On [DATE] at 4:45 p.m., the administrator provided a copy of the resident's current care plan. Review of the care plan found a focus statement related to the right side extremities being weaker than the left, and contractures of the right shoulder, elbow, wrist, and hand. However, there was no goal related to what the facility hoped to achieve related to contracture maintenance, and no interventions on how the facility planned to ensure no worsening of the contractures, or no negative outcomes related to the contractures. During an interview on [DATE] at 4:01 p.m., Director of Rehabilitation Services #52 said this resident first began therapy services [DATE] through [DATE]. Their old record keeping was done on paper and they had transferred to electronic documentation sometime in (YEAR). She reviewed the numerous times this resident had physical therapy (PT) and/or occupational therapy (OT) services in (YEAR) and found the following: - She was on PT and OT caseload [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. - She again received PT and OT services [DATE] through [DATE]. - She was on PT caseload [DATE] through [DATE]. Director of Rehabilitation Services #52 said she assumed the resident had a hospitalization in there somewhere. - She received OT services [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. Director of Rehabilitation Services #52 said they screened every patient in the facility at least every three (3) months at the time their quarterly assessments were due, and on patients after they sustained a fall. She said they also have a HEY program whereby they keep referral sheets at every nursing station. She said if any employee within the facility had a concern about a resident's functioning, they could communicate their concerns to therapy by utilizing the referral sheets. Director of Rehabilitation Services #52 said they screened this resident on [DATE] after she was readmitted to the facility following a psychiatric inpatient admission. They found that she was able to propel in a wheelchair around the facility and there was no change in functional transfers. Upon inquiry, she said the last time OT had her on case load was (MONTH) (YEAR). At that time, OT had goals for passive and active range of motion (ROM) to the right upper extremities, ten (10) repetitions for three (3) sets daily to establish a contracture management program. OT also had goals for her to tolerate a right hand orthotic for two (2) hours initially, with the goal to tolerate it long-term for four (4) hours. The final long-term OT goals were to discharge the resident to the restorative program with 100% staff training for the contracture management program. She said the director of nursing (DON) was the head of the restorative program. In an interview on [DATE] at 4:15 p.m., the DON said therapy did not say to pick her back up for restorative when they did her screening upon her return to the facility following that (MONTH) psychiatric hospitalization . Upon inquiry, she said this resident had not received restorative services since her return to the facility on or around [DATE]. On [DATE] at 4:22 p.m., during a joint interview with the DON and Director of Rehabilitation Services #52, the DON said the resident used to have a Posey roll. She said the resident also used to receive restorative services with the restorative aides. The DON said that formerly this resident had physician orders [REDACTED]. The DON said the old orders expired, and there were no new admission orders [REDACTED]. She said PT completed a screening upon her return to the facility from the hospital, and did not order restorative services or the Posey hand roll. She said that in all likelihood this may have fallen through the cracks. The DON said she felt that nursing assistants did enough range of motion during the activities of daily living to make it count for range of motion. The DON and Director of Rehabilitation Services #52 said they would check with therapy the next day to see if they want her picked back up again for restorative services. On [DATE], interviews with Nurse Aides (NA) #64 and #38, at 5:30 p.m. and at 5:35 p.m., respectively, revealed they were trained in nurse aide classes to exercise limbs of residents who had paralysis. NA #38 said she was assigned to provide care for this resident that day. She said she knew to exercise the affected limb. She said she has had no instructions to apply any type of splint, orthotic, carrot, or Posey roll to the affected hand. During an interview with the resident on [DATE] at 9:41 a.m., she demonstrated that she could use her left hand to try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three (3) middles fingers on the right hand were contracted and she could not stretch them out. The three fingers were bent downward, and then pointed back toward the wrist. The fingernails that could be visualized were trim. There was no odor noted. During an another interview with Director of Rehabilitation Services #52 on [DATE] at 1:20 p.m., she said that OT looked at the resident and determined that she had not sustained any decline in functionality. She said they picked her back up on caseload. On [DATE] at 8:15 a.m., during an interview with OT #11, a box with a Posey hand splint inside was noted on her desk that had the resident's name written in black marker on the outside of the box. OT #11 said she assessed the resident yesterday and saw no decline in the functionality of the resident's right hand. She said the functionality of the resident's hand was the same as it was during the time she had most recently received therapy services. When asked what would happen if the resident did not wear the Posey hand splint, she said the palm of the resident's hand would become macerated, and her contracted fingertips could intrude into the palm. When asked if she would always need to wear a device of that type, she replied in the affirmative. She said the contracture would not correct itself at any time in the future, so it would be a lifetime need for the device. When asked whether the restorative service aides or the regular aides on the floor would apply the Posey when she was discharged from OT, she said only the restorative aides would apply it. She said the regular aides on the floor did not apply orthotics, and would not do so unless the policy changed sometime in the future to allow the aides to do so. She agreed that upon her return from the hospital in March, that she should have been picked up again for restorative and for the orthotic, and she was not. | 2020-09-01 |
| 17 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 329 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident remained free of unnecessary drugs. The physician ordered a reduction of Resident #9's [MEDICATION NAME] more than two (2) months after the pharmacist recommended the reduction. Two (2) days after the ordered reduction, the medication was increased without any evidence the increase was needed. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #9. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report with a date of 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of [MEDICATION NAME] at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was sixty-four (64) day after the initial recommendation. On 04/13/17 the physician ordered a reduction to 0.25 mg at bedtime for one (1) week and then discontinue the [MEDICATION NAME]. On 04/15/17 the physician discontinued [MEDICATION NAME] 0.25 mg at bedtime and restarted [MEDICATION NAME] 0.5 mg at bedtime. Review of the behavioral flow sheet for (MONTH) of (YEAR) did not reveal behaviors related to anxiety. Review of nursing notes between 04/13/17 and 04/15/17 did not reveal documentation of the resident experiencing anxiety. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the records did not reveal any indication of a need for increasing the [MEDICATION NAME]. | 2020-09-01 |
| 18 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 353 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, visitor interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure sufficient staff to implement resident care plans and respond to residents' needs for thirty-four (34) of thirty-four (34) residents reviewed for restorative services (#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141) and twelve (12) residents (#93, #125, #34, #43, #103, #126, #41, #121, #22, 104, 189, and #93) observed during the dining experience. Facility census: 116. Findings include: a) Resident #76 Medical record review found a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17 that identified Resident #76 required the extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m. found Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m., the resident was in bed lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 slid down in bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Licensed Practical Nurse (LPN) #62 observed the resident and confirmed he was not positioned correctly and needed pulled up in bed. She asked the NA to assist her to position him correctly to eat his meal. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. c) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. d) Residents #101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days a week; Restorative nursing to provide BLE PROM in all planes . re-evaluate in 90 days and PRN. The record indicated no services offered on 05/01/17, 05/02/17, 05/06/17, 05/09/17, 05/10/17, 05/12/17, 05/14/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/20/17, or 05/21/17. - Resident #49: Restorative to ambulate resident two (2) times daily 50 feet with hemi-walker and CGA six (6) days a week, initiated on 05/13/17. The restorative log indicated the facility failed to offer services for eight (8) of twelve (12) days and for twenty (20) of thirty two opportunities. Restorative nursing to transfer resident from bed to w/c or w/c to armchair .six (6) times a week. Restorative was not offered for eight (8) of 12 opportunities. - Resident 124: Resident to attend restorative dining six (6) times a week, lunch meal The restorative log indicated the order was not completed as ordered from 05/01/13 through 05/24/17. - Resident #187: Restorative staff to assist resident to ambulate 150 feet twice a day with roll walker .six (6) days a week Restorative nursing to provide transfer training from w/c to chair .six (6) times a week. Services were not provided for thirteen (13) opportunities. e) Daily Staffing and Assignment sheets for 04/16/17 to 05/24/17, reviewed on 05/24/17 at 10:45 a.m., indicated restorative nursing was transferred from restorative services to nurse aide assignment services for all or part of a day on 05/19/17, 05/18/17, 05/17/17, 05/16/17, 05/08/17, 05/07/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17 (late), 04/27/17, 04/25/17, 04/24/17, 04/21/17, 04/19/17 04/18/17, 04/16/17. The assignment sheets also indicated only one (1) NA was assigned and/or performed restorative services on 05/24/17, 05/23/17, 05/22/17, 05/19/17, 05/21/17, 05/19/17, 05/17/17, 05/16/17, 05/15/17, 05/14/17, 05/12/17, 05/09/17, 05/08/17, 05/06/17, 05/05/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17, 04/23/17, 04/22/17, 04/21/17, 04/17/17, and 04/16/17. f) The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed residents had not received restorative services as per physician's orders [REDACTED]. New orders, dated 05/25/17 to 05/26/17 to discontinue and/or reduce restorative services to four (4) days a week included 27 of 27 residents reviewed: Resident #27, #61, #26, #150, #49, #141, #187, #195, #160, #101, #105, #21, #31, #20, #47, #153, #61, #125, #45, #107, #192, #5, #112, #84, #121, and #16. The administrator, at 6:40 p.m. on 06/01/17, requested to share the facility's quality assurance action plan. The administrator verbalized a staffing concern had been identified on 03/24/17 and a plan initiated that date to address concerns related to restorative services. The administrator said the facility was reviewing the services monthly to determine if the plan was working and if not, would revise it again. The administrator said that on 05/25/17 the program was reviewed and revised to reduce restorative care to four (4) days a week, as that was manageable for the facility and what residents were routinely receiving and required. g) Residents #93, #125, #34, #43, #103, #126, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: fine dining 11:25 a.m. rehab (restorative) 11:30 a.m. south hall 12:10 p.m. south hall 12:15 p.m. east hall 12:20 p.m. east hall 12:30 p.m. north hall 12:35 p.m. north hall 12:40 During a random observation, on 06/01/2017 12:50 p.m., an overhead page announced, Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. At 12:55 p.m.,on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. NA #34 informed Resident #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides were passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m. RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m. Resident #41 was asleep, her meal tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m. Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m. LPN #94 walked by the room of Resident #41 and #103, but did not stop or try to awaken the residents who had not started eating their meals. h) Residents #104, #189, and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late 30 to 60 minutes. i) During an interview with the interim CNE, on 06/01/17 at about 2:15 p.m., an inquiry was made as to who the facility addressed staffing concerns. The CNE verbalized the restorative nursing staff was pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. With inquiry as to how staff functions during the evening meals and on weekends when administrative staff is not in the facility to assist, the CNE verbalized the weekend manager assisted. Discussion included that four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17. | 2020-09-01 |
| 19 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 362 | E | 0 | 1 | ELSQ11 | Based on observation, staff interview, resident interview, and review of the dining schedule, the facility failed to ensure sufficient staffing to prepare and serve food in the scheduled timeframes. This practice affected twelve (12) residents served in their rooms during lunch dining. Facility census: 116. Resident identifiers: Residents #93, #125, #34, #43, #41, #121, #22 #104, #189, and #63 Findings include: a) Residents #93, #125, #34, #43, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: -- fine dining 11:25 a.m. -- rehab (restorative) 11:30 a.m. -- south hall 12:10 p.m. -- south hall 12:15 p.m. -- east hall 12:20 p.m. -- east hall 12:30 p.m. -- north hall 12:35 p.m. -- north hall 12:40 b) During a random observation on 06/01/2017 12:50 p.m., a staff member announced by the overhead page Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by the entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. The dining schedule indicated the trays shoud have been served at 12:20 p.m. Observation revealed no resident on the hallway had a meal tray. c) At 12:55 p.m. on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. The dining schedule indicated the floor trays were served at 12:10 p.m. NA#34 was heard informing Residents #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m., RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m., Resident #41 was asleep, her meal tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m., Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m., LPN #94 walked by the room of Resident #41 and #107, but did not stop or try to awaken the residents who had not started eating their meals. The resident response list on the South Hall, dated 06/01/17 at 2:52 p.m., identified Resident #93, Resident #67, and Resident #77 were totally dependent for eating. Those who required extensive assistance included Residents #125, #107, #117,#129, #34, #18, #5, and #9. d) Residents #104, #189 and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. - meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 e) During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late, 30 to 60 minutes. f) During an interview with the interim Center Nurse Executive on 06/01/17 at 2:15 p.m., when asked to whom the facility addressed staffing concerns, the CNE said the restorative nursing staff were pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. When asked how staff functioned during the evening meals and on weekends when administrative staff were not in the facility to assist, the CNE said the weekend manager assisted. ( Four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17.) | 2020-09-01 |
| 20 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 428 | D | 0 | 1 | ELSQ11 | Based on record review and staff interview, the facility failed to act upon a pharmacist's recommendation in a timely manner. This was true for two (2) of five (5) residents reviewed for unnecessary medications. The physician did not respond to a pharmacist's recommendation for Resident #9 for over two (2) months. For Resident #45, the resident continued to receive the medication Reglan nearly three (3) months after it should have been discontinued. Resident identifiers: #9 and #45. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report dated 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of Clonazepam (a psychoactive medication) at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was 64 days from the initial recommendation. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the physician's response to the pharmacist's recommendation was not timely. b) Resident #45 A pharmacist review dated 02/09/17 identified Resident #45 received Reglan 5 mg every 8 hours and was also taking Protonix 40 mg daily with both medications being for gastroesophageal reflux disease (GERD). The pharmacist's recommendation was to consider tapering the Reglan while continuing the Protonix. The physician accepted the recommendation with a modification of discontinuing the Reglan on 02/25/17. Review of the Medication Administration Record [REDACTED]. On 05/31/17 at 1:36 p.m., the DON agreed the resident continued to receive Reglan after the physician noted to discontinue the medication on 02/25/17. | 2020-09-01 |
| 21 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 431 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the Centers for Disease Control (CDC) and Prevention guidelines, and review of manufacturer's guidelines, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD - a test to aid in the detection or [DIAGNOSES REDACTED]. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection from this vial. One (1) of two (2) medication storage room refrigerators contained a vial of PPD serum that was not labeled when initially opened. Facility census: 116. Findings include: a) East wing medication room refrigerator Observation of the East wing medication room refrigerator on 05/17/17 at 7:56 a.m., accompanied by Licensed Nurse (LN) #55, found an opened, partially used vial of Purified Protein Derivative (PPD) serum which contained no date indicating when it had first been opened. When full, the vial contained enough serum for ten (10) tests. The nurse said the vial should have been dated when it was first opened, so that staff could determine how long the vial had been in use. She said they should discard all opened vials of PPD after they were opened for thirty (30) days. She immediately discarded the opened vial of PPD. During an interview with the director of nursing on 05/17/17 at 5:00 p.m. she said the nurse informed her of the opened undated vial of PPD. She said their policy directed that all multi dose vials be dated initially when opened, and discarded in accordance with the manufacturer's guideline. The Centers for Disease Control and Prevention (CDC) guidelines include, If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The Aplisol PPD manufacturer's guidelines includes, Vials in use for more than thirty (30) days should be discarded due to possible oxidation and degradation which may affect potency. | 2020-09-01 |
| 22 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 441 | E | 0 | 1 | ELSQ11 | Based on observations, staff interview, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection to the extent possible. Staff failed to utilize proper hand hygiene, failed to utilize personal protective equipment (PPE) when required and/or dispose of PPE properly, and failed to handle medication properly. These practices affected nine (9) of the one hundred sixteen (116) residing in the facility and had the potential to affect additional residents. Facility census: 116. Resident identifiers: #25, #189, #127, #76, #104, #42, #31, #163, and #158. Findings include: a) Residents #25, #189, #127, #76, #104, and #42 During a lunch meal observation, Nurse Aide (NA) #75 touched items in the room of Resident #25, returned to the cart, poured a cup of coffee and placed it on top of the cart. The NA entered the room of Resident #189 who was in contact isolation for clostridium difficile (a highly contagious organism). The NA did not don personal protective equipment (PPE) prior to entering the room. Upon completion of the tray set-up, NA #75 washed her hands for a count of eight (8) seconds. The NA exited the room and poured coffee for Resident #68. Without performing hand hygiene, the NA passed trays to Resident #76 and assisted NA #135 with Resident #104. Upon completion, the NA washed her hands for a count of seven (7) seconds, then passed a tray to Resident #42. b) Resident #25 On 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 performed care for Resident #25. Upon completion, the NA bagged soiled items. With the same gloves the NA pulled up the resident's covers, picked up the bed remote from the floor and attached the call bell to the bed cover. c) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Nurse Aide (NA) #102 assisted Licensed Practical Nurse (LPN) #72 with wound care. The resident held Resident #163's hands. When the nurse unfastened the resident's brief, she found the resident had an incontinence episode. The NA removed her gloves and without performing hand hygiene exited the room. Upon return, the NA went to the bathroom and donned gloves. Upon completion of care, the NA removed her gloves and exited the room without utilizing hand hygiene. During care, Resident #163 pulled the barrier on the nightstand and a plastic bag with wound care supplies fell to the floor. Upon completion of wound care, LPN #72 removed her gloves and used hand sanitizer. The LPN picked up the plastic bag from the floor which contained gloves and four by four gauze pads. She placed the tube of cream utilized for wound care and the wound care cleanser in the bag. LPN #72 picked up the bag in her right hand and the garbage bag with her left hand and exited the room. She stopped at the treatment cart, placed the bag on top of the cart without first cleansing it, then placed it in the drawer, laying it across the top of other opened bags which contained other residents' supplies, still without cleansing the bag. d) Resident #31 A random observation on 06/01/17 at 4:24 p.m., revealed an isolation cart stationed outside of Resident #31's door. A small trash can, located on the right side of the resident's bed, near the foot of the bed, contained a yellow isolation gown protruding over the top of the garbage can. An isolation mask was located on the floor bedside the bed. Upon request, Licensed Practical Nurse (LPN) #60, completed an observation and said, Not cool. The nurse said the gown should be in a covered container and asked AD #36 to obtain one. The resident was identified as having shingles. e) Housekeeping During a random observation on 05/23/17 from 11:59 a.m. until 12:24 p.m., a bucket of mop water was noted spilled in the hallway at the room of Resident #50. Housekeeping (HSK) #133 and physical therapy assistant (PTA) cleaned the spill using towels to wipe up the contents. They did not wear PPE. Upon completion, HSK #133 wiped her hands down the sides of her uniform pants, as if to further dry them. f) During an interview on 05/30/17 at 2:58 p.m., Registered Nurse (RN) #6, the infection control coordinator, said the facility's policy required staff wash hands for a minimum of twenty (20) seconds. The nurse said the washcloths utilized for peri care should not have been placed in the sink basin, and PPE was required prior to entering the room of the resident in isolation. The RN identified Resident #189's infection as clostridium difficile, which required stringent hand hygiene. The nurse verbalized LPN #72 should have sanitized the bag she picked up from Resident #163's floor, prior to placing it back in the cart, but would have obtained a new bag herself. g) The hand hygiene policy with a revision date of 11/28/16, required staff perform hand hygiene before patient care, before an aseptic (clean) procedure, after any contact with blood or other body fluids even if gloves were worn, after patient care, and after contact with the patient's environment. The policy noted staff might decontaminate with alcohol based rub or wash hands with soap and rub vigorously for 20 seconds, covering all surfaces of hands and fingers. h) Resident #158 During medication administration observations on 05/16/17 at 8:16 a.m. Licensed Practical Nurse (LPN) #132 obtained a box from the drawer of her medication cart which contained Breo Elipta (an inhaler). She carried the box into Resident #158's room, and set the box directly onto the resident's bedside stand. She removed the inhaler and handed it to the resident to use. After the resident finished with the inhaler, LPN #132 placed the inhaler back into its box. She then placed the box directly onto the countertop of the resident's sink while she washed her hands. She then placed the box back into the drawer of the medication cart. During an interview with the director of nursing on 05/17/16 at 5:15 p.m., the risk of possibly transmitting pathogens by not maintaining a barrier between clean objects (medication box) and resident furnishings during the medication pass was discussed. She agreed, and said she would educate the nurse. | 2020-09-01 |
| 23 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 514 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records. For Resident #190, neurological assessments were incomplete. For Resident #163, documentation regarding treatments, response to pain medication, and a voiding diary were incomplete. For Resident #159, [MEDICAL TREATMENT] communication sheets and activities of daily living (ADLs) date were incomplete. ADL sheets were incomplete for Resident #76 and meal/snack percentages were not documented for Resident #143. This was true for five (5) of thirty-two (32) records reviewed. Resident identifiers: #190, #163, #159, #76, and #143. Facility census: 116. Findings include: a) Resident #190 Review of the resident's medical record on 05/30/17 found he sustained an unwitnessed fall in his room on 04/10/17 at 5:05 p.m. As a result of the fall, he incurred an abrasion and a skin tear to the back of his left arm between his elbow and shoulder. The facility initiated a neurological assessment flow sheet right away. On 04/11/17 at 4:30 p.m. and at 8:30 p.m., the flow sheet was silent for neurological assessments, vital signs, observations, or staff signatures. The assessment resumed on 04/12/17 at 12:30 a.m. On 05/30/2017 at 4:04 p.m., after reviewing the neurological assessment flow sheet, the director of nursing (DON) agreed there was incomplete documentation on 04/11/17 at 4:30 p.m. and at 8:30 p.m. with no documented refusals, and noted the night shift picked it back up as did the day shift, with no abnormalities noted. b) Resident #163 1. Review of the resident's medical record and treatment administration records for (MONTH) and (MONTH) (YEAR), found no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17, and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml (milligrams per milliliter) administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17, and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). 3. The three (3) day incontinence management diary, dated 04/12/17 through 04/15/17, revealed no data for 9 of 36 opportunities including 7:00 a.m. to 9:00 a.m., 9:00 a.m. to 11:00 a.m., 11:00 a.m. to 1:00 p.m., and 1:00 p.m. to 3:00 p.m. on 04/14/17 and 04/15/17, and 11:00 p.m. to 1:00 a.m. on 04/12/17. c) Resident #159 1. [MEDICAL TREATMENT] communication records, reviewed for the period from 12/15/16 to present, revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for the facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records were found for 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., when asked what the facility's responsibility related to the permacath and graft site were, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, March, and (MONTH) (YEAR). 2. Activity of daily living records reviewed for (MONTH) (YEAR) revealed omissions of data for meal percentages for 05/30/17, 05/29/17, 05/27/17, 05/26/16, 05/08/17, and 05/06/17. Omissions related to snacks included 05/31/17, 05/30/17, 05/29/17, 05/27/17, 05/26/17, 05/24/17, 05/16/17, 05/09/16, 05/08/16, 05/06/17, and 05/04/17. The interim CNE reviewed the medical record on 06/01/17 and confirmed the record was not complete. d) Resident #76 05/30/17 at 10:24:05 p.m., review of the resident's activities of daily living (ADL) records found incomplete data for bed mobility, transfers, eating, toilet, walking, locomotion, dressing, personal hygiene, bathing, meals, bladder, and bowel for dates 05/07/17, 05/08/17, 05/11/17, 05/12/17, 05/17/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/24/17. e) Resident #143 Review of the resident's medical record related to nutrition revealed omissions of data for meal percentages and bedtime snacks. The (MONTH) (YEAR) activity of daily living records noted omissions of data for 18 of 93 opportunities for meals on 05/31/17, 05/30/17, 05/26/17, 05/22/17, 05/21/17, 05/20/17, 05/13/17, 05/02/17, and 05/01/17. Snack data omissions included 6 of 31 opportunities for snacks on 05/30/17, 05/29/17, 05/26/17, 05/25/17, 05/05/17, and 05/02/17. | 2020-09-01 |
| 24 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 558 | D | 0 | 1 | 8Y4111 | Based on observation, resident interview and staff interview, the facility failed to provide appropriate accommodation of needs regarding storage and accessibility of Resident #23's personal items. This was evident for one (1) randomly observed resident. Resident identifier: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser drawer was found to be in disrepair and not functionable. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The broken drawer was hanging in such a way that it also blocked access to the bottom dresser drawer. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her personal items in the middle or bottom dresser drawers due to the front of the middle drawer falling apart and hanging in the way. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get what ever supplies he will need to fix it today. | 2020-09-01 |
| 25 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 580 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19. The wound care and dry dressing was applied daily from 04/04/19 until 04/10/19 when it was documented refused and applied again daily on 04/11/19 until 04/14/19 when it was documented as refused. The wound care treatment and dry dressing was applied daily again on 04/15/19 until 04/18/19 when it was documented refused. The wound care treatment and dry dressing was applied on 04/19/19, 04/20/19, 04/21/19, 04/24/19, 04/27/19, and 04/28/19. On 04/22/19, 04/23/19, 04/25/19, 04/29/19, and 04/30/19 it was documented refused, and on 04/26/19 there was no documentation either way as to refusal or provision of wound care treatment and the dry dressing, the TAR entry was blank. In the month of (MONTH) 2019 the resident had twenty seven (27) opportunities to have wound care treatment and a dressing applied daily and had the ordered treatment randomly eighteen (18) times. There was no wound care treatment provided at all during the month of May. According to the TAR, R#33 refused wound care treatment and daily dressings twenty-nine (29) days in the month of May, and two (2) days there was no documentation either way as to refusal or application of wound care or the dry dressing, the TAR was blank on those two days. According to the TAR, R#33 refused treatment on (MONTH) first, second, third, and fourth; and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to refusals. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment as ordered and it was documented treatment was provided as ordered on only eighteen (18) days, and three (3) days there was no documentation either way as to refusal or provision. There was no documented evidence the physician was notified of the resident's refusals until 06/05/19, when the order was discontinued. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. R#33 said he did not want a dressing on it now. R#33 said, I had training myself and if I wanted a dressing I'd ask for it, but it doesn't need one. When asked where he had training and what kind of training he had, the resident did not answer but informed this surveyor he was done talking about it. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Notify physician of the refusal of treatment. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's noncompliance with wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to R#33 medical record revealed non-compliance and refusal of care in other areas other than wound treatment. | 2020-09-01 |
| 26 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 584 | D | 0 | 1 | 8Y4111 | . Based on policy review, resident interview, staff interview and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment. Through a random opportunity for discovery, it was found Resident #23 had a busted up air conditioning unit that was in disrepair. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser and HVAC (centralized heating ventilation and air conditioning system) unit in her room were found to be in disrepair and maintained in an unsafe manner. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The Resident's HVAC unit in her room was found to be in poor condition with the plastic framing that enclosed the heating busted in several places, along the top and sides. The HVAC unit was loose and had came unattached from the right-hand side of the heating unit sliding down over the temperature control knob, causing the temperature control knob to be very difficult to turn. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her dresser drawers due to the front of the middle drawer falling apart. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer, and she was unable to adjust the heat on the HVAC unit due to the broken plastic frame, so she just left it on one setting (high heat) and had gotten used to hot temperature. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get whatever supplies he will need to fix it today. In regard to the broken plastic framing around the HVAC unit, the Administrator stated, I will have our maintenance guy go to storage right now and see if we have another HVAC unit that we can use to replace this immediately, this is not acceptable. | 2020-09-01 |
| 27 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 585 | D | 0 | 1 | 8Y4111 | Based on policy review, Resident interview, staff interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have. This was true for two (2) of four (4) reviewed in the care area of personal property. Identified Resident's #115 and #82. The facility census was111. Findings included: a) Facility policy Facility Grievance/Concern Policy with a revision date of 03/01/18 stated: --The purpose for grievance /concern reporting is ensure that any patient/patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form. --To assure prompt receipt and resolution of the grievance/concern. --Notify the person filling the grievance/concern of resolution within 72 hours. b) Resident #115 During an interview on 06/04/19 at 12:51 PM, Resident #115 stated, that while at the hospital her TV and google home was reported to be missing when she returned, but nothing has been done about it. A review of the Grievance/Concerns reports revealed that there was not a form filled out about the missing items. During an interview on 06/06/19 at 11:30 AM, Administrator was asked about a Grievance/Concern report on this missing TV and Google home. He stated that an employee that is no longer here spoke to Resident # 115, about her missing items, but for whatever reason there was not a form completed. During an interview on 06/10/19 at 9:11 AM, Administrator provided a completed Grievance/ Concern form, dated 06/06/19, he stated that he did look for Resident # 115 missing items and they could not be located. He stated, that the facility will have to replace them. b) Resident #82 During an interview on 06/03/19 at 1:45 PM, Resident #82 stated, that her red satin [NAME]et with a white strip has been missing for a while and that she did tell the Administrator, but nothing has been done. She went on to say, that some of the staff said, that they have looked for it, but all they did was put things in her closet that does not belong to her. During an interview on 06/06/19 at 11:15 AM, Administrator asked Resident #82 about her missing [NAME]et. He said to her that he thought they had found and returned her red [NAME]et. Resident #82 applied to him, that they put a man's tan [NAME]et in her closet, and that was not hers and it is not even red. Administrator looked though her closet with her consent and presents, no red satin [NAME]et was found. On 06/10/19 at 9:11 AM, Administrator provided a Grievance/ Concern form dated; 06/06/19 concerning the red [NAME]et. It stated, that a search for the [NAME]et was done, the item was not located and will be replaced with a like item. | 2020-09-01 |
| 28 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 656 | D | 0 | 1 | 8Y4111 | Based on observation record review and staff interview, the facility failed to develop a care plan for discharge planning. This was true for one (1) of one (1) reviewed in for the care area of discharge planning. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #117. Facility Census: 111. Findings included: b) Resident #117 A review of the medical record on 06/05/19 for Resident #117 revealed the comprehensive care plan had not been developed to include discharge planning. In an interview on 06/05/19 at 3:22 PM, Social Services Specialist (SSS) #101 verified the care plan for Resident #117 was not developed to include discharge planning. | 2020-09-01 |
| 29 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 657 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan related to refusal of care and non-compliance. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). This practice had the potential to effect more than a limited number. Resident identifier: #33. Facility census: 111. Findings include: a) Resident #33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's ongoing noncompliance with daily wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing daily wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to the ongoing refusal of daily wound care treatment. The CNE also confirmed based on R#33 medical record showing non-compliance and refusal of care in other areas the care plan should have been revised to address refusal of care in those areas as well. | 2020-09-01 |
| 30 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 676 | D | 0 | 1 | 8Y4111 | Based on resident interview, staff interview, observation and record review, the facility failed to ensure care and services for the following activities of daily living; Hygiene, bathing, dressing, grooming, and oral care for Resident #33 and #78. This was true for two (2) of two (2) reviewed in the care area of ADLS. Also, the facility failed to provide a communication board for Resident #105. This was true for one (1) of one (1) in the care area of communication. Resident identifiers: #33 and #78. Facility census: 111. Findings included: a) Resident #33 During an interview on 06/03/19 at 10:56 AM, Resident #33 said, that it is hard to get the aides to help him with a shower, they seem to pass him to another aide, and they take a lot of smoke brakes. He stated, that he must give himself a bed bath. When asked how long it had been since his last shower, he stated, that he did not know only that it has been too long. A review of the of the ADL records revealed that Resident #33 is scheduled to get a shower on Wednesdays and Saturdays, and he had no showers or baths for the month of April, and one (1) shower in the month of May. There was 15 days between his last shower until the shower he received on 06/06/19. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL recorded and agreed that Resident #33 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff members. b) Resident #78 During an interview on 06/03/19 at 12:14 PM, Resident #78 complained that it was hard to get a shower, and it had been ever since the one shower has been broken. He stated that the shower had been for down for months. He had below the shoulder length hair that appeared oily. A review of the ADL record revealed Resident #78 was scheduled to have showers on Tuesdays and Fridays. Review of ADL records revealed Resident # 78 in the month of (MONTH) he went 20 days without a shower or bath, and from (MONTH) 24th to (MONTH) the 6th that was 12 days without a shower or bath. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL records and agreed that Resident # 78 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff. c) R105 During an observation with R105 on 06/04/19 at 9:14 AM it was discovered the word/letter board she used as a communication system was found in very poor condition, with food particles, water stains and frayed edges. The regulation requires any communication devices used by residents to be in good repair. In an interview with E84, Licensed Practical Nurse (LPN) on 06/05/19 at 8:44 AM, verified the communication board was in very poor repair and needed to be replaced. | 2020-09-01 |
| 31 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 684 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy review, the facility failed to ensure and provide needed care and services in accordance with professional standards of practice for two residents reviewed during the annual LTCSP (Long Term Care Survey Process). This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who was not provided education on wound care and infection control. This was true for one (1) of five (5) sample residents reviewed for falls that was not provided neuro checks appropriately after a fall. This practice had the potential to affect a limited number. Resident identifier: R#33 and R#60. Facility census: 111. Findings included: a) R#33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she did not document notifying the physician about the refusal of treatment or any education concerning wound care or infection control. LPN#84 said she was aware there was still some occasional minimal drainage from the wound site. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment or any documentation or evidence that patient education was provided to the resident concerning wound care, disease processes, or infection control. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage; the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment, particularly advising or educating the resident of consequences of refusal. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed the resident should have been provided education by staff regarding wound care, infection control, and disease processes that influence healing, and was not. b) Resident #60 On 06/10/19 at 09:55 AM, medical record review revealed Resident #60 had endured an un-witnessed fall on 05/22/19 at 3:00 PM while transferring from wheelchair to bed. Licensed Practical Nurse (LPN) #110 documented that the Resident stated (typed as written), I hit head but not hurting. At that time, LPN #110 implemented neurological assessments (screening tool used post fall for monitoring and detection of head injury) with a start time of 3:00 PM. The neurological assessments were completed for the following dates and time: --05/22/19 at 3:00 PM --05/22/19 at 3:30 PM --05/22/19 at 4:00 PM --05/22/19 at 4:30 PM --05/22/19 at 5:30 PM --05/22/19 at 6:30 PM --05/22/19 at 7:30 PM --05/22/19 at 8:30 PM --05/23/19 at 12:30 AM --05/23/19 at 4:30 AM The neurological assessment flow sheet was found to be incomplete with no data in all the following categories: level of consciousness, pupil response, hand grasps, movement of extremities, and pain response for nine (9) of the ten (10) assessments completed. The first neurological assessment completed on 05/22/19 at 3:00 PM was the only neurological assessment found to be completed in its entirety. Review of the facility's Neurological policy on 06/10/19 at 11:20 AM revealed the following guidelines for completion of neuroglial assessments (after an unwitnessed fall) to be done at the following frequency: --Every 30 Minutes x 2 hours, then --Every 1 hour x four hours, then --Every four hours x 24 hours. Further review of the neurological assessment sheet revealed the neurological assessments were discontinued without completion for the frequency as indicated. The last neurological assessment was completed on 05/23/19 at 4:30 AM, for a total of ten (10) assessments. In order to complete the neurological assessments for the correct number of times as indicated in the facility's Neurological policy, fourteen (14) assessments should have been done with an end time and date of 05/23/19 at 8:30 PM. During an interview on 06/10/19 at 11:28 AM the Director of Nursing (DON) agreed that the neurological assessments for the Resident was not completed correctly. The DON stated the expectation is for nursing staff to complete all information on the Neurological Assessment Flow sheet, and nothing should ever be left blank. The DON also stated, Yes we stopped the neurological assessments too soon, we did not complete the 24-hour frequency. At 1:10 PM on 06/10/19 during an interview, LPN #110 verified the portion of the Neurological Assessment Flow Sheet that she completed, and agreed the assessments were not completed correctly and should not have been left blank for level of consciousness, pupil response, motor response, and pain response. LPN #110 stated, It just gets so busy around here, and it's hard to get everything done because it's so hectic, I should have done better. | 2020-09-01 |
| 32 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 689 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and Policy review the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifier: #53. Facility census 111. Findings included: a) Resident #53 1. Policy review Facility Waste Management policy directed personnel to: --Discard contaminated sharps immediately be disposed in a sharp's container. --Not discard sharps in routine trash. 2. Observation During an interview on 06/04/19 at 9:40 AM, with the Resident #53's roommate, this surveyor observed Resident #53 in her wheelchair at the sink with the water running. Resident #53 then moved herself over to the window. Licensed Practical Nurse (LPN) #85 entered the room and asked if she could turn off the water. She turned off the water and picked up a blue razor from the sink and threw it in the trash can under the sink. Resident #53 wheeled herself to the sink and removed the razor from the trash can. With the razor on her lap she wheeled herself back in front of her window and began the shave her left leg. Upon closer observation it was noted that her left ankle was bleeding. 3. Interviews This surveyor asked a passing employee get a nurse and distracted the resident with conversation. LPN #85 returned to the room and looked at Resident #53's left. LPN #85 left the room to retrieve supplies to treat the cuts to Resident #53's legs. There were seven (7) cuts on her left leg from the razor. On 06/04/19 at 10:00 AM, LPN #85 and Nurse Unit Manager (NUM) #61 returned to the room with supplies to treat the wounds. LPN #85 was asked how it Resident #53 had access to a razor. She said she uses the razor for the hairs on her chin, but she does it for her. Resident # 53 stated, that she does not remember where she got the razor from. During an interview with Administrator on 06/06/19 at 11:30 AM, was asked where the razors where kept. He stated they were stored in the clean utility room that had a coded lock on the door, inside the room they were stored in a drawer. He stated, that he does not understand how Resident #53 got a razor. During an interview on 06/10/19 at 10:00 AM, Director of Nursing (DoN) stated, that she has removed all razors from the utility rooms and put them in the medication rooms that are locked and only the nurses have access to and the NA have to sign the razors out and back in with a nurse for disposal. She agreed this was an avoidable accident. | 2020-09-01 |
| 33 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 690 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#68. Facility census: 111. Findings include: Observations of Licensed Practical Nurse (LPN#84) providing catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. LPN#84 first provided pressure ulcer wound care to R#68 for three (3) different areas on the resident's buttocks prior to providing catheter care. During the provision of care the resident was assisted to turn multiple times from side to side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed strong tension, pulling, and stretching of the drainage tubing was occurring at times. The Foley catheter drainage tube's taut tension, pulling, and stretching had the potential to cause injury to the resident's urethra and urinary meatus. After LPN#84 stated she was finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. LPN#84 then acknowledged the resident did not have an anchor device on and should have, and that she also forgot to anchor and secure the tubing when she did the catheter care. LPN#84 confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. | 2020-09-01 |
| 34 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 695 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed R28 was not receiving her oxygen therapy at the prescribed flow rate. Resident identifier: #28. Facility census: 111. Findings included: a) Resident #28 A medical record review for Resident #28 on 06/04/19 revealed a physician's orders [REDACTED]. During an observation on 06/04/19 at 7:56 AM, it was discovered the oxygen concentrator for R28 was administering one and a half (1.5) liters of oxygen via nasal cannula and not the prescribed two (2) liters. Licensed Practical Nurse (LPN) #110 on 06/04/19 at 7:59 AM verified the oxygen concentrator for R28 was set on (1.5) liters and not the prescribed two (2) liters. | 2020-09-01 |
| 35 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 880 | E | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. This was true for observations made in the laundry room regarding an inadequate negative air pressure. This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who had an exposed open draining wound. This was true of one (1) of three (3) sample residents reviewed for catheter care where a disposable contaminated wipe was placed back in the package with other uncontaminated disposable wipes. This was true for one (1) of four (4) sample residents reviewed for feeding tubes, who had a soiled feeding tube syringe laying out in the open not bagged. This was true for random observations made on two (2) separate occasions for a resident with a Foley catheter; one (1) observation revealed the Foley catheter drainage bag on the floor and one (1) observation revealed the Foley catheter drainage tubing on the floor. This practice had the potential to effect more than a limited number. Resident identifier: R#33, R#68, and R#23. Facility census: 111. Findings included: a) Laundry Room Inspection of the laundry room on 06/06/19 at 09:26 AM with the Environmental Services Director and the Director of Maintenance revealed the laundry room exhaust fan that provided the negative airflow in the dirty laundry room was not working properly. The Director of Maintenance after inspecting the exhaust fan said the exhaust fan was barely pulling air. The Environmental Services Director and the Director of Maintenance both acknowledged there was not adequate negative air flow in the dirty laundry room due to the poor performance of the exhaust fan. Both the Environmental Services Director and the Director of Maintenance confirmed the inadequate negative air flow in the dirty laundry room created an infection control issue. The Director of Maintenance said he would immediately have the fan fixed. b) R#33 - an open draining wound During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident has a history of having abscesses that have needed to be treated with incision and drainage (I&D) procedures. The resident last abscess was on his right side and on 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment untill 06/05/19. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings and that the open wound was a breech of infection control principals. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed an open draining wound is an infection control issue. c) R#68 disposable wipes Observations of Licensed Practical Nurse (LPN#84) providing peri-care (washing the genitals and anal area) and catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed a breech in infection control principals. LPN#84 used packaged disposable wipes to provide the peri-care and to clean around the catheter drainage tube inserted in the resident's urethra. When the LPN finished providing peri-care she took her soiled gloved hand that was contaminated from providing peri-care and pushed a clean unused disposable wipe back into the package, thus contaminating the package of disposable wipes. LPN#84 acknowledge this was a breach in infection control principles. d) Resident #23 On 06/05/19 at 10:50 AM observation was made of a 60 milliliter (ml) syringe in Resident's room lying on her bedside table. The syringe was open to air, placed on top of a pile of papers beside a used tissue. The syringe appeared to be soiled with light brown crusty residue inside the syringe and along the tip. Liscensed Practical Nurse (LPN) #110 verified that syringe belonged to Resident #23, and it had been used for bolus tube feedings. LPN #110 agreed the syringe was not stored properly and discarded syringe into the trash. The syringe did not have any information written on it to indicate the time/date it was initiated for use. Review of facility's Enteral Feeding policy revealed instructions to label and date syringe, store in plastic bag or appropriate container, and the syringe can be used for 24 hours. During an interview on 06/05/19 at 12:30 PM the Director of Nursing (DON) agreed the syringe was maintained in an unsanitary manner. The DON stated, The syringe was improperly stored and should have been dated. Moving forward better measures will be taken. e) R68 On 06/03/18 at 2:01 PM during a random opportunity for discovery a catheter bag belonging to R68 was found on the floor under her bed. During an observation on 06/03/19 at 2:03 PM with E114 assistant center nurse executive (ACNE) verified the catheter bag was on the floor and not securely attached to R68's bed. On 06/04/19 at 12:42 PM during a random opportunity for discovery the catheter tubing was dragging on the floor under R68's wheel chair. During an observation on 06/04/19 at 12:44 PM with E27 nursing assistant (NA) verified the drainage tubing was dragging on the floor and not securely attached under R68's wheelchair. A review of the policy for Care of Indwelling Urinary Catheter revised on 02/01/19 states, Secure catheter tubing to keep the drainage bag .off the floor. | 2020-09-01 |
| 36 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 684 | D | 0 | 1 | KVZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to provide appropriate treatment and care in accordance with physician orders [REDACTED]. This affected one (#160) of one sampled resident reviewed as a new admission. The facility census was 113. Findings included: Resident #160 was observed sitting up in bed on 07/16/18 at 10:15 AM. At the time of the observation, Resident #160 was interviewed. He stated he had not received his pain medication when he was admitted to the facility. Resident #160 also stated he did not get all his routine medications in a timely manner. He stated his sister brought in his medications from home and he took those. The medical record review for Resident #160 was completed on 07/19/18 at 5:30 PM. The census tab of the electronic record documented Resident #160 was admitted on [DATE] at 8:13 PM with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The documentation revealed Resident #160 did not receive the aspirin until one day after admission on 07/15/18 at 10:00 PM. The [MEDICATION NAME] was administered three days after admission on 07/18/18 at 6:00 AM. The [MEDICATION NAME] bisulfate was administered two days after admission on 07/16/18 at 9:00 AM. The [MEDICATION NAME] was administered four days after admission on 07/18/18 at 9:00 AM. the Tylenol administered two days after admission on 07/16/18 at 12:15 AM. Review of the weights and vitals summary on 07/19/18 at 5:30 PM revealed Resident #160 had vital signs documented approximately 5 hours after admission on 07/15/18 at 1:12 AM. The second set of vital signs was dated four days later at 07/18/18 at 7:32 PM. There was no documentation of any vital signs taken upon admission. An interview was conducted with the unit manager, Registered Nurse (RN) #23 on 07/18/18 at 6:10 PM. She stated according to the electronic record, Resident #160 was admitted on [DATE] at 8:13 PM. She verified the progress notes did not indicate the date and time Resident #160 was admitted . RN #23 verified Resident #160 did not receive his medications as ordered by the physician according to the Medication Administration Record [REDACTED]. An interview with RN #23 on 07/19/18 at 10:45 AM revealed the expectation of the facility was newly admitted residents received their medications within 24 hours. An interview on 07/19/18 at 12:00 PM with the pharmaceutical technician from the pharmaceutical company revealed Resident #160's medications were delivered within 24 hours on 07/15/18 at 5:34 PM. | 2020-09-01 |
| 37 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 801 | D | 0 | 1 | KVZF11 | Based on staff interviews, the facility failed to employ a full-time Dietary Manager that met the qualifications to manage the food and nutrition services. The facility census was 113. Findings included: On 07/18/18 at 5:00 PM, Food Service Director #121 was interviewed. Food Service Director #121 stated he was not a certified dietary manager. He stated he took the position of Food Service Director one week ago. He was not currently enrolled in a program for certification. Food Service Director #121 stated he was told he was going to be enrolled in the training program but did not know when. Food Service Director #121 verified he did not have any nutrition schooling or a college degree in nutrition. He verified he was not a certified food service manager and did not have a national certification for food service management and safety from a national certifying entity. On 07/19/18 at 1:27 PM, Regional Vice President #144 was interviewed. He verified Food Service Director #121 did not meet the qualifications for food service management and was not currently enrolled in a program for certification. | 2020-09-01 |
| 38 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 812 | E | 0 | 1 | KVZF11 | Based on observations, staff interview, review of cleaning logs and review of the facility policy, the facility failed to maintain the kitchen environment and equipment in a sanitary manner. This affected one of one kitchen. The facility census was 113. Findings included: On 07/17/18 at 10:57 AM, observations were made in the kitchen with Food Service Director #121. Observations revealed a build-up of food debris on the outside of the cabinet where the hot plate bases were stored. Additionally, a stainless table that holds the toaster had food debris build-up. The lower base cabinets under the prep sink on the back wall of the kitchen had food debris build up. The outside of a warming unit cabinet had a build-up of food debris and the windows around the prep area and prep sink had splatters that looked like food debris. Food Service Director #121 verified the food debris build-up on the hot plate holder cabinet, stainless table, lower base cabinets under the prep sink and the dirty windows. Immediately following the observations on 07/17/18 at approximately 11:00 AM, Food Service Director #121 provided the daily and weekly cleaning logs for (MONTH) (YEAR). The daily and weekly cleaning logs revealed daily and weekly cleaning tasks for the kitchen. The Cleaning Scheduled record revealed no documentation the equipment and work areas including the tables were cleaned by the evening cook assigned to do the task. On 07/11/18, the external plate warmer, bread warmer and work areas, including tables were not documented as being cleaned by the morning cook. On 07/11/18, the weekly cleaning of the base cabinets was not documented as being cleaned by the evening cook. Food Service Director #121 verified documentation of the cleaning was not complete and stated they (the staff) may have just wiped the areas with a rag and sanitizer but did not clean the areas thoroughly to remove the build-up of food debris. Food Service Director #121 was not sure if the cooks had followed the cleaning schedule due to the lack of documentation. Food Service Director #121 verified the food debris buildup on the hot plate holder, tables, cabinets and windows. On 07/19/18 at 1:27 PM, the policy on Cleaning Standards for Food and Nutrition Services revised and dated 06/15/18 was provided by Regional Vice President #144. The policy revealed the purpose was to ensure all food service equipment and areas are clean and sanitary. The process included: Employees utilize the cleaning procedures when completing assigned cleaning duties. Regional Vice President #144 verified the policy was not followed for cleaning equipment of food debris in the kitchen. | 2020-09-01 |
| 4634 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 225 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, family interview, and policy review, the facility failed to report and/or investigate allegations of neglect for one (1) of seven (7) residents reviewed for allegations of neglect. Staff failed to identify allegations of neglect, consequently, the facility failed to report and/or investigate allegations Resident #83 did not receive adequate and timely incontinence care. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 During an interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she related she had entered the facility on 02/09/16 at lunchtime. The MPOA said she changed her mother and, There was no sign of stool in her brief, but when I wiped her vagina, there was a ball of stool with a little bit of blood. She related she looked for Registered Nurse (RN) #34, but as she was at lunch, she spoke with Licensed Practical Nurse (LPN) #72, who said she would pass it on. Resident #83's daughter added that her mother was hosptalized on [DATE] related to a urinary tract infection [MEDICAL CONDITION] related to E-coli (Escherichia coli - an organism found in the colon). She said her mother returned to the facility on [DATE], at which time she spoke with the director of nursing (DON) and RN #34 regarding her concerns about her mother not being cleaned. She added that on 02/18/16, she entered the facility at 7:00 a.m. and her mother was at breakfast. The daughter related her mother returned to the room around 8:00 a.m. and when providing incontinence care, again wiped stool from the resident's vagina, but there was no stool in the resident's brief. She said the infection control nurse entered the room and she showed her the washcloth with the stool on it. On 02/24/16 at 8:15 a.m., review of complaints, grievance logs, and incidents reported to State agencies, found no evidence that the MPOA's concern regarding feces in the resident's vagina on 02/09/16, which was reported to LPN #72; the MPOA's concerns about the resident not being kept clean that she voiced to the director of nursing and RN #34 on 02/16/16; or the finding of feces in the resident's vagina on 02/18/16 and reported to the infection control nurse, had been identified as allegations of neglect. None of these incidents were identified as possible neglect and reported to the administrator and required State agencies, or investigated. During an interview with Registered Nurse #34 at 2:08 p.m. on 02/26/16, the nurse related she had received the complaint on 02/16/16 related to Resident #83 not being cleaned properly and staff had not provided care when requested by the resident. The nurse related she had educated staff, but had not reported the allegation of neglect to the appropriate entities, including the administrator, director of nursing, or State agencies. RN #34 acknowledged she had not completed an investigation regarding the allegation. The nurse related she did not believe it to be an allegation of neglect and did not realize it should have been reported. RN #34 also confirmed a complaint/grievance/concern form had not been completed. On 02/26/16 at about 9:00 a.m., LPN #72 related she had not completed a grievance/concern form related to any of the complaints received from the resident's MPOA. The abuse prohibition policy, reviewed on 02/24/16 revealed the purpose was to ensure the Center staff were doing all that was within their control to prevent occurrences of abuse and neglect. The policy indicated staff would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent; clinical examinations for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The policy required the facility to ensure documentation of witnessed interviews were included. | 2019-08-01 |
| 4635 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 226 | E | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, family interview, and policy review, the facility failed to implement its abuse/neglect policies for one (1) of seven (7) residents reviewed for allegations of neglect. The facility staff failed to identify allegations of neglect and failed to report and/or investigate the allegations that Resident #83's medical power of attorney voiced relative to the resident not receiving adequate and timely incontinence care. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 During an interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she related she had entered the facility on 02/09/16 at lunchtime. The MPOA said she changed her mother and, There was no sign of stool in her brief, but when I wiped her vagina, there was a ball of stool with a little bit of blood. She related she looked for Registered Nurse (RN) #34, but as she was at lunch, she spoke with Licensed Practical Nurse (LPN) #72, who said she would pass it on. Resident #83's daughter added that her mother was hosptalized on [DATE] related to a urinary tract infection [MEDICAL CONDITION] related to E-coli (Escherichia coli - an organism found in the colon). She said her mother returned to the facility on [DATE], at which time she spoke with the director of nursing (DON) and RN #34 regarding her concerns about her mother not being cleaned. She added that on 02/18/16, she entered the facility at 7:00 a.m. and her mother was at breakfast. The daughter related her mother returned to the room around 8:00 a.m. and when providing incontinence care, again wiped stool from the resident's vagina, but there was no stool in the resident's brief. She said the infection control nurse entered the room and she showed her the washcloth with the stool on it. On 02/24/16 at 8:15 a.m., review of complaints, grievance logs, and incidents reported to State agencies, found no evidence that the MPOA's concern regarding feces in the resident's vagina on 02/09/16, which was reported to LPN #72; the MPOA's concerns about the resident not being kept clean that she voiced to the director of nursing and RN #34 on 02/16/16; or the finding of feces in the resident's vagina on 02/18/16 and reported to the infection control nurse, had been identified as allegations of neglect. None of these incidents were identified as possible neglect and reported to the administrator and required State agencies, or investigated. During an interview with Registered Nurse #34 at 2:08 p.m. on 02/26/16, the nurse related she had received the complaint on 02/16/16 related to Resident #83 not being cleaned properly and staff had not provided care when requested by the resident. The nurse related she had educated staff, but had not reported the allegation of neglect to the appropriate entities, including the administrator, director of nursing, or State agencies. RN #34 acknowledged she had not completed an investigation regarding the allegation. The nurse related she did not believe it to be an allegation of neglect and did not realize it should have been reported. RN #34 also confirmed a complaint/grievance/concern form had not been completed. On 02/26/16 at about 9:00 a.m., LPN #72 related she had not completed a grievance/concern form related to any of the complaints received from the resident's MPOA. b) The facility's abuse prohibition policy, reviewed on 02/24/16 revealed the purpose was to ensure the Center staff were doing all that was within their control to prevent occurrences of abuse and neglect. The policy indicated staff would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent; clinical examinations for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The policy required the facility to ensure documentation of witnessed interviews were included. | 2019-08-01 |
| 4636 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 246 | D | 0 | 1 | 4CE211 | Based on a random observation, staff interview, and family interview, the facility failed to ensure reasonable accommodations of needs for Resident #83. The resident's call light was not within reach. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 An interview with Confidential Interviewee (CI) #1, revealed Resident #83's call bell was sometimes placed out of reach. The interviewee related the resident sometimes rang the bell a lot and did not think the staff liked it. An interview with CI #2 revealed Resident #83 required assistance with all of her basic needs. CI #2 related the resident was able to ring her call bell and sometimes rang it about every fifteen to twenty (15-20) minutes. The interviewee related the resident sometimes stayed on the light, and staff had to keep going back in the room. Review of the resident's care plan on 02/24/16 at 8:30 a.m., revealed it included, Frequently on call light wanting care provided although care just provided The care plan also indicated the resident sometime threw it (the call bell) and/or other things on the floor. The Kardex, a brief care plan for nurse aides, instructed, Place call light within reach. On 02/24/16 at 10:44 a.m., Nurse Aide #97 performed incontinence care for Resident #83. Upon completion, the NA exited the room. The resident was positioned on her back and the call bell was attached to the upper portion of the side rail at the head of the bed on the resident's right side. Upon inquiry, Resident #83 related she was capable of ringing her call bell if desired. Upon request for a demonstration, the resident reached for the call bell with her right hand, but could not reach the call bell. She then rolled toward the right and tried to use her left hand, but still could not reach the call light. Upon request, Resident #83 demonstrated for NA #97 she was unable to reach the light. The resident's medical power of attorney was also present during the demonstration. An interview with the director of nursing, on 02/24/16 at about 5:00 p.m., confirmed the call bell should have been placed within the resident's reach. | 2019-08-01 |
| 4637 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 272 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately complete a comprehensive assessment to reflect the active [DIAGNOSES REDACTED]. Resident identifiers: #115 and #60. Facility census: 117. Findings include: a) Resident #115 On 02/24/16 at 6:00 p.m., a review of Resident #115's current physician's orders [REDACTED]. A review of the resident's care plan on 02/25/16 at 12:12 p.m., found an intervention, with the revision date of 10/13/15, Receives Anti-depressant: Administer [MEDICATION NAME] ([MEDICATION NAME]). On 02/25/16 at 12:33 p.m., review of the resident's significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/16/15, found Item I5800 depression (other than [MEDICAL CONDITION]) was not coded to identify the resident had an active [DIAGNOSES REDACTED]. In an interview on 02/25/16 1:07 p.m., Clinical Case Coordinator Registered Nurse (CCCRN) #70 stated, I reviewed the significant change MDS and the MDS should have been coded as the resident having either depression or dysthymic disorder either under I5800, or I1800 - other additional active diagnosis. b) Resident #60 A review of the medical record on 02/25/16 at 9:00 a.m., revealed the Significant Change MDS, with an ARD of 12/22/15, revealed Section I - Active Diagnoses, did not include gout as a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] 100 milligrams (mg) once daily for gout since 11/30/15. During an interview on 02/25/16 at 9:33 a.m., the MDS Coordinator reported she did not complete Section I of the comprehensive MDS assessment accurately to include the [DIAGNOSES REDACTED]. | 2019-08-01 |
| 4638 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 312 | D | 0 | 1 | 4CE211 | Based on observation, confidential interview, staff interview, medial record review, resident interview, and family interview, the facility failed to ensure one (1) of two (2) dependent residents reviewed for activities of daily living received the necessary care and services to maintain good oral hygiene. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 A Stage 1 family interview on 03/23/16 at 2:43 p.m., revealed Resident #83 did not receive activities of daily living (ADL) assistance with oral care needed to maintain good oral hygiene. The family member related the resident had partial plates which were broken and missing one (1) tooth. The care plan, reviewed on 02/24/15, at approximately 8:30 a.m., indicated staff would assist Resident #83 with oral care daily. The Kardex, a care plan utilized by nurse aides, indicated the resident had likely dental cavities and partial dentures A confidential interview on 02/24/16, revealed Resident #83 only received oral care when she requested it. The interviewee was not aware of any dental concerns related to natural teeth or the resident's dentures, and was not aware the resident's partial denture was broken. An observation on 02/24/15 at 1:30 p.m., revealed thick stringy debris in the resident's mouth. Upon inquiry as to how often oral hygiene was provided by staff, the resident related it was not often and not daily. An interview with the director of nursing (DON) indicated oral care should be provided every day and as needed. . | 2019-08-01 |
| 4639 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 315 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and family interview, and competency record reviews, the facility failed to ensure two (2) of five (5) residents observed for incontinence care received appropriate treatment and services to prevent urinary tract infections. Improper techniques were utilized during incontinence care. Resident identifiers: #83 and #6. Facility census: 117. Findings include: a) Resident #83 An interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she said she had found the resident had not received good incontinence care on several occasions. She had reported she had found the resident unclean to Registered Nurse (RN) #34 about two (2) weeks prior to Resident #83's hospitalization on [DATE]. She said on 02/09/16 at lunch time, she changed her mother and found, There was no sign of stool in her brief, but when I wiped the resident's vagina, there was a ball of stool with a little bit of blood. She related she had spoken with Licensed Practical Nurse (LPN) #72, who said she would pass it on. She further added, on 02/18/16 she entered the facility at 7:00 a.m. when her mother was at breakfast. The resident returned to her room around 8:00 a.m. and when providing incontinence care, the daughter again wiped stool from her vagina. She related the infection control nurse entered the room and she showed her the washcloth and took the brief home with her. During an observation and interview on 02/24/16 at 1:45 p.m., Resident #83 said she was wet and needed changed. The resident related staff had not asked her if she needed changed after lunch. Observation of the room continued until staff entered the room to perform care. At 3:33 p.m., Resident #83 was placed back in bed and incontinence care was provided by NA #97 and NA #73. The NA utilized washcloths, and did not apply peri-wash until an inquiry as to the product used to clean her. Further review of the medical record, on 02/26/16 revealed a physician's orders [REDACTED]. . b) Resident #6 A random observation of incontinence care, on 02/25/16 at 10:12 a.m., revealed Nurse Aide (NA) #17 providing incontinence care to Resident #6. The NA cleansed the resident, and without changing gloves or performing hand hygiene applied lotion, labeled z-guard to the resident's buttocks, then to the the resident's peri-area. An interview with Licensed Practical Nurse (LPN) #65, immediately following the observation revealed the nurse aide utilized improper technique, posing a risk of cross contamination. The NA should have applied the z-guard to the perineal area before applying it to the resident's buttocks. | 2019-08-01 |
| 4640 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 441 | E | 0 | 1 | 4CE211 | Based on observation, staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to maintain an infection control program to prevent the transmission and spread of disease and infection to the extent possible. Staff handled soiled briefs and clean and soiled linens incorrectly, staff failed to utilize proper hand hygiene during management of impaired skin integrity and incontinence care. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #83 and #6. Facility Census: 117. Findings include: a) Resident #83 1. An observation of incontinence care on 02/23/16 at 1:41 p.m., revealed the resident had a large loose bowel movement. After setting up supplies, the director of nursing (DON) removed the resident's brief and proceeded with incontinence care with the assistance of Licensed Practical Nurse (LPN) #72. Observation revealed excoriation and denuded areas on the resident's groin, inner thigh gluteal folds, and buttock areas. The areas were bright red in color, and the resident related they were painful. Additionally, an elongated area on the coccyx was open and contained a yellow slough-like substance. After cleansing Resident #83's buttocks with peri-wash, LPN #72 removed the soiled sheet and placed a clean sheet beneath the resident's buttocks and applied a clean brief. The LPN requested the Phytoplex nourishing skin cream from the DON. With soiled gloves and without performing hand hygiene, the DON picked up the lotion and placed it on LPN #72's soiled glove used to remove the bowel moment. The LPN proceeded to place the cream over all of Resident #83's wounds LPN #72 removed her gloves and washed her hands for a total count of nine (9) seconds. After the wash basin was rinsed, the DON removed her gloves, and with un-gloved hands placed the contaminated lotion container in the bath basin and placed the basin in the resident's closet. 2. During an observation on 02/24/16 at 10:44 a.m., Nurse Aide (NA) #87 provided incontinence care to Resident #83. The NA cleansed stool from the resident. Without changing gloves and/or performing hand hygiene, placed a clean brief on the resident, and then obtained clean linens, which had been placed at the foot of the bed, and proceed to change the resident's bed linens. b) Resident #6 A random observation of Nurse Aide (NA) #17 providing peri-care for Resident #6, on 02/25/16 at 10:12 a.m., revealed a soiled brief on the floor near the head of the resident's bed, a washcloth lying in the sink basin, and a soiled gown on the floor near the foot of the bed. Upon completion of peri-care, the NA applied ointment without changing gloves or performing hand hygiene. NA related no gloves were available, which was why she did not change them. Immediately following the observation, an interview with Licensed Practical Nurse (LPN) #65 related neither the brief, nor the gown should have been on the floor, and the washcloth should not have been in the sink. The nurse related garbage bags should have been placed at the foot of the bed for soiled items and related the practices posed a potential for cross contamination. During an interview at 10:45 a.m. on 02/25/16, NA #17 commented the facility's practice included linens and soiled briefs were to be bagged and should not be on the floor. c) An interview with the infection control nurse on 02/25/16 at 12:45 p.m., revealed infection control practices had been identified as an issue and staff had been educated on handwashing and peri-care. She said she had been working on it the past week, and indicated the educations were initiated on 02/17/16. d) The facility's handwashing policy and CDC guidelines require staff utilize hand hygiene after removing gloves, before and after direct resident care, immediately after contact with blood and body fluids . non-intact skin . when moving from contaminated body site to clean body site during patient care, after contact with inanimate objects in the immediate vicinity of the resident . and after removing gloves. The proper technique included . rub hands vigorously for at least fifteen to twenty (15-20) seconds covering all surfaces of the hands and fingers | 2019-08-01 |
| 4740 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 157 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the responsible party, of an incapacitated resident, when the resident experienced a significant weight loss within thirty (30) days. This was true for one (1) of eleven (11) resident's reviewed during a complaint survey ending on 07/07/16. Resident identifier: #5. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16 - 107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. Further record review found the physician had determined the resident lacked capacity to make medical decisions. The date the incapacity statement was signed by the physician was illegible. The incapacity statement noted the incapacity was long term. The resident had the inability to process information due to Dementia and a [MEDICAL CONDITIONS]. The resident had appointed her son as her MPOA on 05/13/03. Review of the most recent minimum data set (MDS), a significant change MDS, with an assessment reference date (ARD) of 04/25/16, found the resident's score on her brief interview for mental status (BIMS) was a four (4). A score of 0-7 indicates severe cognitive impairment. At 8:54 a.m. 07/07/16, the director of nursing (DON) was asked to provide verification the resident's medical power of attorney was notified of the weight loss. At 10:22 a.m. on 07/07/16, the administrator was asked if she could provide verification the resident's MPOA was notified of the resident's weight loss. At 10:50 a.m. on 07/07/16, the registered dietician (RD), #122, was interviewed. RD #122 confirmed the resident had a 16.9% weight loss between 04/04/16 and 05/03/16. She had no information to present verifying the resident's MPOA was notified of the significant weight loss. At the close of the survey at 2:30 p.m. on 07/07/16, no further information had been provided. | 2019-07-01 |
| 4741 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 280 | D | 1 | 0 | R67611 | > Based on record review and staff interview, the facility failed to revise the care plan for Resident #2 when the resident's therapeutic diet changed. This was true for one (1) of eleven (11) resident's whose care plans were reviewed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Review of the resident medical record on 07/05/16 at 2:00 p.m. found a diet order, dated 05/25/16, for a dysphagia advanced diet with thin liquids. Review of the current care plan, updated on 06/13/16, revealed the problem as, Resident is at nutritional risk. The goals associated with this problem were: --Resident will have no signs or symptoms of dehydration and --Resident will maintain a stabilized weight with no significant changes. Interventions included: --Provide regular liberalized dysphagia puree diet with nectar thickened liquids as ordered with 8 ounces whole milk with meals. An interview with the dietary manager (DM), #67, at 4:15 p.m. on 07/05/16 verified the intervention on the care plan addressing nutritional status was incorrect. DM #67 stated the resident no longer received a liberalized dysphagia puree diet with nectar thickened liquids. He stated he diet was upgraded on 05/25/16, after an evaluation by the speech therapist. | 2019-07-01 |
| 4742 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 309 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to consistently assess, monitor and attempt to manage or prevent Resident #7's pain. For Resident #1 the facility failed to follow the physician's orders [REDACTED]. This was true for two (2) of eleven (11) resident's medical records reviewed for quality of care during a complaint survey, ending on 07/07/16. Resident identifiers: #7 and #1. Facility census: 113. Findings include: a) Resident #7 Record review on 07/06/16 at 8:30 a.m. found a sixty-four (64) year old female resident admitted to the facility on [DATE]. The resident was discharged from a hospital, to the facility, for rehabilitation following total bilateral knees arthroplasty on 05/19/16. Other [DIAGNOSES REDACTED]. The facility's nursing notes, upon admission, indicated the resident was alert and oriented and able to voice her needs. Less than twenty-four (24) hours later, on 05/25/16, at 2:02 p.m., the resident was discharged to the hospital. Admitting medications included: [MEDICATION NAME]/[MEDICATION NAME] 5/325 to be administered every 4 hours, as needed, for pain. The hospital discharge summary noted the resident received her last dose of the pain medication at 3:00 p.m. on the day of discharge (05/24/16). Review of the nursing notes found the following documentation: --At 10:30 p.m. on 05/24/16, the resident was refusing to have CMP machine (continuous passive motion machine used for knee joint recovery) placed on at this time, currently waiting on pain medication from pharmacy. Pharmacy request for pain medication was faxed at 7:00 p.m. --A nursing note written at 6:59 a.m. on 05/25/16 revealed the resident resting in bed at this time. Upon putting resident on bed pan noted a small opened area to her right buttocks. Pain medication given as ordered due to the complaint of pain. Resident is complaining of some discomfort at this time but refuses pain medications said she feels different as of last dose given at 3:00 a.m. It was noted the call bell within reach will continue to monitor. --A nursing note written at 1:50 p.m. on 5/25/16 revealed a small amount of bleeding on bandage after dressing change. The resident's husband was at the desk approximately 1:30 p.m. and stated resident has excess bleeding from surgical site on right knee and was very anxious and wanted to go to the hospital. Upon evaluation, resident was anxious, diaphoretic with shortness of breath), complaint of pain and swelling in knee and bleeding was noted on bandage and under knee on sheets. It was also noted the resident's temperature was 99.9 and using oxygen by way of a nasal cannula. The note further stated, the resident was bleeding from the nose and right knee surgical incision with labored breathing and lower extremity [MEDICAL CONDITION]. Physician was notified of change in condition and the resident was sent to the hospital. Review of the medication administration record (MAR), found the resident received only one (1) dose of the [MEDICATION NAME] at 3:00 a.m. on 05/25/16. There was no indication in the medical record the resident's pain was rated at this time and no follow up information, after one (1) hour to indicate if the medication was effective. Review of the physical therapy initial evaluation completed on 05/25/16, found the resident verbally stated she was experiencing pain. The resident rated her pain as a 9 out of 10 indicating severe pain in both knees. Nursing was notified of the resident's pain. The director of nursing (DON) interviewed at 10:52 a.m. on 07/06/16 verified [MEDICATION NAME]/[MEDICATION NAME] 5/325 was available in the facility's emergency medication box. The DON did not know why the nurse was awaiting delivery of the medication when the medication was available at the facility. The DON did say the pharmacy had to be contacted to supply a code to obtain the medication as the medication was a controlled substance. The physician would also need to be contacted for approval to dispense the medication. The DON verified the only dose of [MEDICATION NAME] given to the resident was at 3:00 a.m. on 05/25/16, according to the MAR. Interview with the physical therapist (PT) #37 at 2:10 p.m. on 07/06/16, verified she told nursing the resident was experiencing severe pain. Although her assessment did not include the time of the interview, PT #37 said she was in the resident's room right after breakfast, which she estimated to be around 9:15 a.m. to 9:30 a.m. on 05/25/16. At 4:00 p.m. on 07/06/16, Registered Nurse, (RN) #73, was interviewed. RN #73 was the author of the nursing note written at 10:30 p.m. on 05/24/16. Why asked why she did not obtain the pain medication, [MEDICATION NAME], from the emergency box, she replied, I did get pain medication from the emergency box. She reviewed the MAR and said, I guess I didn't write it down. RN #73 called the pharmacy who faxed verification a code was supplied to obtain the [MEDICATION NAME] from the emergency box. According to the fax information, verification was given at 11:03 p.m. on 05/24/16. RN #73 said she gave the medication shortly after she received the authorization code allowing her to obtain the medication from the facility's emergency supply. RN #73 said she did not follow up on the effectiveness of the medication because she went home at 11:30 p.m. on 05/24/16. At 4:30 p.m. on 07/06/16, the administrator was advised of the above interview with RN #73 and PT #37. She was asked if she could provide any information verifying the following: --Was [MEDICATION NAME] administered around 11:00 p.m. on 05/24/16? --Did staff follow up on the effectiveness of the pain medication given at 3:00 a.m. on 05/25/16? --Did staff follow up on the report of the resident's pain when reported by the PT on the morning of 05/25/16? --Did the facility attempt any non-pharmacological interventions to manage the resident's pain? At the close of the survey at 2:30 p.m. on 07/07/16, no further information had been provided. b) Resident #1 A review of the resident's medical record on 07/06/16 at 3:00 p.m. revealed there were physician orders [REDACTED]. This included do not weight orders dated for 06//12/16. Weight records were evaluated on 07/06/16 and it was found that weights continued for 7/1/16 even though there was do not weigh order. The weight was 126 lbs. On 07/07/16 at 9:45 a.m. with Employee #57 and Employee #111 revealed there was no evidence to support why the weights had continued with current physician's orders [REDACTED]. | 2019-07-01 |
| 4743 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 325 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure two (2) of eleven (11) resident's records reviewed for the care area of nutritional status, maintained acceptable parameters of nutrition. For Resident #5, the facility failed to monitor the resident's significant weight loss (18 pounds in 30 days), and failed to ensure interventions implemented to address the resident's significant weight loss, remained in place. The facility failed to address Resident #9's (who is feed via a Percutaneous endoscopic gastrostomy (PEG) tube) 5 % weight loss and failed to monitor the resident's weight after admission for four (4) weeks to ensure further weight loss did not occur. Resident identifiers: #5 and #9. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16-107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. On 05/10/16 an order was written to discontinue the residents snack and start a house supplement, two (2) times a day, at 10:00 a.m. and 2:00 p.m. through 06/10/16. The Medication Administration Record [REDACTED]. From 05/12/16 to 05/31/16 the resident consumed the following percentages of the house supplement: --05/12/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/13/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/14/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/15/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/16/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/17/16 - no percentages were recorded. --05/18/16 - she refused the morning supplement and consumed 50% of the 2:00 p.m. supplement. --05/19/16 - she refused the morning supplement and consumed 100% of the 2:00 p.m. supplement. --05/20/16 - she refused the morning supplement and consumed 100% of the 2:00 p.m. supplement. --05/21/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/22/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/23/16 - 100% of the supplement was consumed at 10:00 a.m. and 50% at 2:00 p.m. --05/24/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/25/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/26/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/27/16 - no documentation was provided. --05/28/16 - no documentation of the 10:00 a.m. supplement and the 2:00 p.m. percentage recording is illegible. --05/29/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/30/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/31/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. Of the thirty-four (34) occasions in which the percentages of the house supplement were recorded in (MONTH) of (YEAR), the resident consumed an average of 80.8 % of the supplement. The supplement was provided from 06/01/16 until 06/10/16. The supplement was discontinued on 06/10/16. The percentage of consumption of the house supplement for the ten (10) days of (MONTH) (YEAR) is as follows: --06/01/16 - 50% of the supplement was consumed at 10:00 a.m. and 100 % at 2:00 p.m. --06/02/16 - no documentation was provided. --06/03/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/04/16 - no documentation was provided. --06/05/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/06/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/07/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/08/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/09/16 - no documentation was provided. --06/10/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. Of the fourteen (14) occasions in (MONTH) (YEAR) when the supplement was recorded, the resident consumed 96.4% of the supplement. Interview with the dietary manager (DM) #67 at 8:46 a.m. on 07/07/16, verified the resident was no longer on a house supplement. He said, I am just not sure of what happened, that's not my area. At 8:54 a.m. 07/07/16, the director of nursing (DON) was asked what interventions the facility put into place when the resident had an 18 pound weight loss between 04/04/16 and 05/03/16. The DON stated she would have to look at the resident's medical record. The physician's last progress note, dated 05/27/16, was reviewed with the DON who verified the physician did not address the resident's weight loss. The resident did not receive any screenings by the speech therapist, no appetite stimulants etc. The DON said she did not know why the resident's house supplement was discontinued on 06/10/16. At 9:00 a.m. on 07/07/16, the resident was observed eating breakfast in her room. Nurse Aide (NA) #1 was feeding the resident her breakfast. NA #1 stated, She eats like a bird, but she will drink. The resident was observed taking very small, slow bits of her oatmeal. After approximately five (5) bites of the oatmeal, the resident refused to open her mouth. When NA #1 offered her a carton of milk, the resident readily drank through a straw. At 10:22 a.m. on 07/07/16, the administrator stated the registered dietician was on her way to the facility to discuss the resident's weight loss. At 10:50 a.m. on 07/07/16, the registered dietician (RD), #122, was interviewed. She stated she recommended the supplement be continued on 06/10/16 and wrote a note indicating the supplement should be continued. She reviewed her electronic note, written on 06/10/16, in the medical record. She said, I don't know what happened, the resident would have been reviewed again this week. RD #122 explained supplement orders are written for thirty days. At the end of the 30 days the resident is re-evaluated and if the resident is consuming the supplement, the order is continued. Employee #122 was unaware the resident was not receiving the supplement. RD #122 calculated the resident's weight loss from 04/04/16 to 05/03/16 as a 16.9% weight loss in 30 days. She confirmed the only intervention for the weight loss was the house supplement which had been discontinued on 06/10/16. The daily percentages of the consumption of the house supplement was reviewed with the RD. She agreed the resident was consuming the majority of the supplements which is why she wanted to continue the house supplement. Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 04/25/16 noted the resident was on a physician-prescribed weight gain regimen. The resident's MDS also reflected the resident had no swallowing or choking issues, and no loss of liquids/solids from mouth when eating or drinking. The resident's current care plan address the problem of, At nutritional risk with an intervention of house supplements two (2) times a day at 10:00 a.m. and 2:00 p.m. b) Resident #9 Review of Resident #9's medical record at 12:30 p.m. on 07/05/16 found she had been discharged to an acute care hospital a total of six (6) times in the last 12 months. The last discharged took place on 06/22/16. The Director of Nursing (DON) indicated the resident would not be returning to the facility because she passed away while at the hospital. Resident #9's most recent admission prior to her final discharge was on 06/02/16. The resident was readmitted to the facility after an eleven (11) day stay in the hospital which began on 05/22/16. Upon readmission the facility on 06/02/16 the facility obtained the residents weight which was recorded at 100.5 pounds (lbs). Prior to discharge from the facility Resident #9's last recorded weight was obtained on 05/20/16 at which time she weighed 107 lbs. During her hospital stay Resident #9 lost 6.5 lbs. or 6 percent (%) of her body weight. (All percentages of weight loss were calculated using the following formula (usual weight - actual weight)/usual weight X 100 = % of body weight loss.) Registered Dietician (RD) #122 evaluated Resident #9 upon her readmission to the facility on two separate occasions within the first week of her readmission. RD #122 evaluated the resident on 06/03/16 and 06/07/16. On each assessment RD #122 noted the following (typed as written): --Under the heading evaluation and nutritional plan she noted, Readmission review. DX (diagnosis): aspiration PNA (pneumonia) and PEG replaced. NPO (nothing by mouth). Resident triggers for a SWL (Significant weight loss) X 6 months on readmission and wt. (weight) loss trend X 1 and 3 months. BI (body mass index) wnl (within normal limits) Current TF (tube feeding) not meeting est. (estimated) needs. Under the heading Nutrition Interventions LD #122 noted, Rec. (recommend) TF levity 1.5 @ (at) 40 cc (cubic centimeters)/ (per) hr (hour) x (times) 20 hrs (hours) w/ (with) current flushes = 1200 kcal (Kilocalorie), 51 gm (grams) prot. (protein), 600 cc free fluid, 1200 cc w/ flushes. ST (speech therapy ) eval (evaluate) for possible po (by mouth) diet. Please consult RD if po diet ordered. Both assessments indicated the resident BMI was 19.63 and her estimated needs daily were 1,104 calories, 55 grams of protein, and 1,380 cc's of fluid daily. The assessment dated [DATE] indicated that the resident was receiving [MEDICATION NAME] 1.5 at 25 cc's per hour continuously. RD #122 indicated on this assessment that Resident #9 was only receiving 900 calories and 1056 cc's of fluid. Therefore she was not meeting her estimated needs and RD #122 recommended that it be increased to 40 cc's per hour for 20 hours per day on 06/03/16. This recommendation was implemented by facility staff on 06/03/16. The next assessment completed by RD #122 on 06/07/16 indicated the resident at this time was receiving [MEDICATION NAME] 1.5, 40 ccs per hour for 20 hours for a total of 1200 calories and 1200 ccs of fluid. However, her recommendation on this assessment was to have the TF be 40 cc's per hour for 20 hours which Resident #9 was all ready receiving. She also noted in her assessment on 06/07/16 that the TF was not meeting the residents estimated needs. RD #122 did however clarify that statement in a progress note dated 06/22/16, the day Resident #9 was discharged from the facility for the final time. RD #122 indicated in the progress note that there was an error to her assessment dated [DATE] and it should read, TF meeting residents estimated needs. Resident #9 was not assessed by the dietician after 06/07/16. Resident #9 was again weighed on 06/09/16 at which time she weighed 95.2 lbs. She lost an additional 5.3 lbs. or 5 % of her body weight during her first week back at the facility. This represents severe weight loss. There were no additional weights obtained for Resident #9 while at this facility after the weight on 06/09/16. Review of Resident #9's nursing progress notes found a weight warning note dated 06/15/16 which read as follows: Resident was recently readmitted to the facility after an extended hospital stay where she lost a significant amount of weight due to illness. Will monitor for additional changes and notify HCS (health care surrogate) and physician as appropriate. Further review of the record found no evidence the physician and/or the RD was ever notified of Resident #9's additional weight loss of 5% during her first week back in the facility. There was also no evidence in the medical record that nursing ever identified that part of her weight loss occurred after readmission to the facility nor did they intervene to evaluate for further weight loss or to prevent further weight loss. Review of the facility's policy titled Weights and Heights with an effective date of 06/01/01 found all residents are to be weighed upon admission and/or readmission, then weekly for four week and monthly thereafter. The facility failed to implement this policy for Resident #9. She was only weighed on admission then for one (1) week. She was not re-weighed at the conclusion of her second week at the facility and was discharged prior to the conclusion of her third week. Therefore the facility was not able to identify if the resident continued to experience weight loss. The above findings were reviewed with the DON at 3:40 p.m. on 07/05/16. She confirmed Resident #9 had not been weighed weekly per facility policy. She stated that she should have had at least one more weight prior to her discharge on 06/22/16. She indicated that she would have to look to see if they had addressed the weight loss she suffered after readmission to the facility. At the time of exit on 07/07/16 at 2:30 p.m. no additional information was provided. An interview with RD #122 at 10:52 a.m. on 07/07/16 confirmed she had seen the resident on two (2) occasions since her readmission to the facility on [DATE]. She indicated she had not seen or assessed Resident #9 after she lost and additional 5% of her body weight during the first week of her readmission. RD #122 indicated that every week she will print a report which identifies any weight loss and she must have missed Resident #9's on the week of 06/09/16. | 2019-07-01 |
| 4744 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 329 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure Resident #8's drug regimen was free from unnecessary medications. Resident #8 received excessive doses of an intravenous (IV) antibiotic. This was true for one (1) of 11 sampled residents. Resident Identifier: #8 Facility Census: 113. Findings include: a) Resident #8 A review of Resident #8's medical record at 1:30 p.m. on 07/06/16 found a physicians order dated 04/06/16 for [MEDICATION NAME] 3.375 milligrams IV every six (6) hours for 10 days. The resident was to receive a total of 40 doses of this medication. Review of the Medication Administration Record [REDACTED]. Resident #8 should have received her last dose of [MEDICATION NAME] on 4/16/16 at 6:00 p.m. however she received four doses on 04/17/16. She received a dose at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. on 04/17/16. She also received a dose at 12:00 a.m. on 04/18/16. These findings were reviewed with the Director of Nursing (DON) at 5:00 p.m. on 07/06/16 and with the Nursing Home Administrator (NHA) in the morning of 07/07/16. At 12:42 p.m. on 07/07/16 the NHA and DON both confirmed they had not additional information to provide in regards to these findings. | 2019-07-01 |
| 4745 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 365 | D | 1 | 0 | R67611 | **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 received the therapeutic diet ordered by the physician. This was true for one (1) of six (6) resident's whose meal service was observed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Observation of the noon meal on 07/05/16 at 12:30 p.m. found Resident #2 eating the substitute meal, a(NAME)salad. The salad contained chunks of breaded chicken on a bed of lettuce. Review of the current physician's orders [REDACTED]. Interview with the speech therapist (PT) #98 at 2:10 p.m. on 07/05/16, revealed a dysphagia diet consists of serving soft vegetables, soft foods, with meats ground up. PT #98 stated a resident on this diet could have lettuce but should not have chunks of breaded chicken. At 3:21 p.m. on 07/05/16, the dietary manager (DM) #67 verified the resident's salad should have had ground chicken instead of the breaded chunks of chicken. DM #67 stated the resident was first served the regular meal which she did not want. The resident then requested the(NAME)salad which was the substitute meal. He said his staff probably did not know who the salad was for when requested by staff serving food in the dining room. | 2019-07-01 |
| 4746 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 508 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to obtain a chest x-ray ordered for Resident #9 by her attending physician. This was true for one (1) of eleven (11) sampled residents. Resident Identifier #9. Facility Census: 113. Findings Include: a) Resident #9 A review of Resident #9's medical record at 12:30 p.m. on 07/05/16 found a physician order [REDACTED]. Incentive spirometry 4 times daily. Repeat CXR (Chest X - Ray) after 4 (four) days. Further review of the record found the following nursing progress notes dated 12/19/16 (typed as written): . Now order to repeat chest x - ray post 4 days of PT left chest . Progress note date 12/21/15 noted, Resident resting in bed at this time. Resident was evaluated by respiratory therapy for incentive spirometry QID (four times a day) and chest PT daily. After initial treatment, resident had some coughing noted but no excretions emitted. Progress note dated 12/22/16 noted, Resident see (sic) by respiratory therapy today for chest pt and incentive spirometry. Resident has had some non productive coughing post incentive spirometry. Breath sounds are diminished in all fields. Respiratory therapy to continue for another two (2) days with follow up chest x-ray to be done on 12/26/15. Further review of the record found no evidence the x-ray ordered for 12/26/15 was ever obtained by the facility. The physician entered a progress note into Resident #9's record on 01/10/16 indicating there resident had completed Chest PT and needed a repeat chest x -ray. The repeat chest x-ray was again ordered on [DATE] and was obtained on 01/11/16. An interview with the Director of Nursing (DON) at 10:46 a.m. on 07/06/16 confirmed the x-ray which should have been obtained on 12/26/15 was not obtained as ordered by the physician. She stated, The next x-ray was not obtained until 01/11/16. She indicated, they must have missed getting it. | 2019-07-01 |
| 4747 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 514 | D | 1 | 0 | R67611 | > Based on record review and staff interview the facility failed ensure complete documentation was in the medical record for meal consumption, snack intake and a neurological assessment. This was evident for four (4) of eleven (11) medical records reviewed. Resident Census was: 113. Findings include: a) Resident #1 On 07/07/16 at 2:25 p.m., a review of the medical record for this resident revealed the facility had not completed daily meal intake documentation. For the month of (MONTH) there were no intakes listed for breakfast on : 06/02, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. There was no documentation of meal intakes at lunch on : 06/02/16, 06/08/16, 06/11/16, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. Likewise, there was no intakes listed for dinner on : 06/07/16, 06/08/16, 06/09/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, and 06/26/16. Snack intakes were only shown to be given on 06/01/16, 06/02/16, 06/03/16, 06/15/16, 06/17/16, 06/18/16, 06/19/16, 06/22/16, 06/23/16, 06/24/16, 06/28/16 and 06/29/16. All the other days of the month were blank with no indication it was given and accepted or refused. b) Resident #3 Documentation of this medical record on 07/07/16 at 2:30 p.m. revealed no documentation for meal intake for the following occasions in (MONTH) (YEAR): --breakfast 06/11/16, 06/17/16, 06/18/16; --lunch: 06/11/16; and --dinner: 6/2/16, 6/6/16, 6/9/16, 6/12/16, 6/19/16, 6/24/16 and 6/26/16. c) Resident #4 A review of this resident's medical record on 07/07/16 at 2:40 p.m. indicated there was no documentation for meal intakes on the following occasions in (MONTH) (YEAR): --breakfast: 06/02/16, 06/11/16, 06/12/16, 06/14/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; --lunch: 06/02/16, 060/3/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; and --dinner: 06/02/16, 06/10/16, 06/12/16, 06/15/16, 06/17/16, 06/19/16, 06/20/16, and 06/25/16. All of these dates were verified with Employee #111 on 07/07/16 at 3:15 p.m. at which time she was given time to present any further evidence of these intakes being recorded. No further evidence was provided. d) Resident #9 Review of Resident #9's medical record at 12:30 p.m. on 07/05/16, found Resident #9 experienced a fall on 09/30/15 at approximately 3:00 p.m. Review of incident report regarding this fall indicated nursing initiated a neurological assessment flow sheet completed for the resident to ensure her neurological status was not harmed when she fell . Review of the Neurological Assessment Flow Sheet initiated for Resident #9 on 09/30/15, found for the following times on 09/30/15 the sheet was not completed in its entirety: 3:00 p.m., 4:00 p.m., 4:20 p.m., 4:35 p.m., 5:00 p.m., 6:00 p.m., 7:00 p.m., and 10:00 p.m. The nurse completing the Neurological assessments at these times failed to document Resident #9's level of consciousness, pupil response, motor functions and pain response. An interview with the Director of Nursing (DON) at 3:40 p.m. on 07/05/16 confirmed the Neurological Assessment Flow Sheet was not completed in its entirety. | 2019-07-01 |
| 5691 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 203 | D | 0 | 1 | WCKU11 | **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 resident and/or the family in writing of: 1) the reason for the resident's discharge from the facility, 2) the effective date of transfer or discharge, 3) a statement that the resident had the right to appeal the action to the State, and 4) the name, address and telephone number of the State long term care ombudsman. This was evident for one (1) of three (3) residents reviewed for the care area of admission, transfer, and discharge. Resident #83 was transferred to a local hospital for exit seeking behaviors. The facility did not provide the resident or family member/legal representative the necessary documentation necessary at the time of the discharge. Resident identifier: #83. Facility census: 108. Findings include: a) Resident #83 The record review for Resident #83, on 01/28/15 at 1:30 p.m., revealed the facility discharged Resident #83 to a local hospital on [DATE] for exit seeking and combative behaviors. During Stage 1 of the Quality Indicator Survey (QIS), the facility provided a copy of information provided to residents upon transfer or discharge. The facility provided a form entitled, Notification of Transfer/Discharge. The form required the facility to complete the effective date of the transfer, the reason for the resident's discharge, a statement that the resident had the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman. At 2:30 p.m. on 01/28/15, the administrator was asked for a copy of the information provided to the Resident #83 and/or his family at the time of discharge. Review of the facility's policy, entitled, Discharge and Transfer found, All patients will receive a Notice of Transfer or Discharge and/or Discharge Transition Plan whenever a voluntary or involuntary transfer/discharge occurs . At 3:00 p.m. on 01/28/15 the medical record clerk, Employee #100, and the administrator confirmed they could find no evidence the required information was provided to the resident/and or the family at the time of discharge. | 2018-08-01 |
| 5692 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 224 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure two (2) of three (3) residents reviewed for nutrition were free from neglect. Goods and services for the prevention of weight loss were not provided as ordered. Resident identifiers: #16 and #74. Facility census: #108. Findings include: a) Resident #16 Review of the weights and vital sign summary found the resident's most recent weight was 117.8 pounds on 01/20/15. The previous recorded weight was 131 pounds on 12/23/14. A nutritional assessment was completed on 11/04/14. The registered dietitian noted the resident had a 7.5% weight loss (a significant weight loss) in the past three (3) months. The dietitian ordered a house supplement and other interventions to address the resident's weight loss. During the survey, on 01/21/15, the resident was still receiving a house supplement, four (4) ounces, two (2) times a day at 10:00 a.m. and 2:00 p.m. At 2:50 p.m. on 01/21/15; the resident was sitting in her chair with a bedside table which contained two (2) cartons of the house supplement. Observation found the resident had not consumed any of the supplements. The paper cartons containing the supplements, were opened; however, the resident had no straw and no glass. Review of the Medication Administration Record [REDACTED]. At 2:57 on 01/21/15, the administrator and the director of nursing (DON) were asked to observe the supplement which was still on the resident's bedside table and to review the MAR. The DON confirmed the consumption of the supplement and the documentation on the MAR indicated [REDACTED] b) Resident #74 Review of the weights and vital sign summary found the resident weighed 165 pounds when admitted on [DATE]. Her last recorded weight was 140.9 pounds on 01/20/15. On 01/06/15, the physician ordered a house supplement, four (4) ounces two (2) times a day, at 10:00 a.m. and 2:00 p.m., for weight loss. At 12:53 p.m. on 01/22/15, review of the MAR found the nurse, Employee #15, had already documented the resident refused her 2:00 p.m. house supplement. The DON and the administrator were asked to review the MAR indicated [REDACTED]. The DON confirmed the 2:00 p.m. snack had not yet been served, although the nurse had already documented it was refused by the resident. c) Review of the facility's policy for Abuse Prohibition found, (Name of the company) will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all patients .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #16 and Resident #74 each had an order for [REDACTED].#15, the nurse responsible for the residents, failed to ensure the supplements were provided, consumed, and/or monitored. The nurse documented Resident #74 refused the supplement more than an hour prior to the receipt of the supplement by the resident. In addition, Resident #16 consumed none of the supplement provided. The same nurse documented the resident consumed 100% of the supplement. | 2018-08-01 |
| 5693 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 225 | F | 0 | 1 | WCKU11 | Based on staff interview and review of employee personnel files, the facility failed to conduct a thorough investigation into the criminal background of one (1) of five (5) employees hired within the past five (5) months. Employee #126 lived out of the state of West Virginia in the previous 5 years. The facility did not complete a fingerprint based criminal background check in the state in which the employee lived. This had the potential to affect all residents residing at the facility. Employee identifier: #126. Facility census: 108. Findings include: a) Employee #126 Review of the personnel files with Employee #27, identified as the bookkeeper, at 3:50 p.m. on 01/26/15 found Employee #126, a nurse aide, had lived in another state from 2007 to 2014. Employee #27 confirmed a criminal background check had not been completed in the other state. | 2018-08-01 |
| 5694 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 241 | D | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one (1) randomly observed resident receiving assistance with eating during a noontime meal. A nurse aide fed Resident #22 while standing beside the resident, rather than sitting down beside the resident and feeding her in a relaxed manner. Resident identifier: #22. Employee identifier: #11. Facility census: 108. Findings include: a) Resident #22 On 01/20/15 at 12:10 p.m., an observation of nurse aide (NA) #11 revealed the nurse aide in Resident #22's room feeding her. Resident #22 was seated in her reclining chair located near the foot of her bed. The NA was standing between the foot of the bed and Resident #22. The NA stood while feeding the resident for the duration of the meal. At 12:20 p.m. on 01/20/15, upon inquiry as to the way a resident should be fed, Employee #11 replied, I knew when I saw you, I should have been sitting down, but my hips hurt too bad to sit down. On 01/20/15 at 2:30 p.m., when made aware of the dining observation, the administrator agreed the NA should have been seated while feeding the resident. | 2018-08-01 |
| 5695 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 242 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, record reviews, review of shower schedules, and staff interviews, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of choices were afforded the right to exercise autonomy regarding an important aspect of their lives. Both residents were not afforded the opportunity to receive their preference for two (2) showers a week. Resident identifiers: #132 and #75. Facility census: 108. Findings include: a) Resident #132 1. At 2:00 p.m. on 01/19/15, Resident #132 was asked if she was able to choose how many times a week she wanted to take a bath or shower. She replied, No I have had only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it the previous week, but it did not do any good because she had still not received a shower. When asked how many showers she would like to have in a week, Resident #132, stated, The two (2) I was scheduled for would be fine with me, but I do not even get those. Observations of Resident #132 made at this time revealed, her hair appeared to be unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15, revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14, Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14, and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 received a shower on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this time frame. 3. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/09/14 when she was discharged back to the hospital. Between 10/17/14 and 12/09/14, Resident #132 was scheduled to receive a shower on 10/20/14, 10/23/14, 10/27/14, 10/30/14, 11/03/14, 11/06/14, 11/10/14, 11/13/14, 11/17/14, 11/20/14, 11/24/14, 11/27/14, 12/01/14, 12/04/14, and 12/08/14. A review of Resident #132's ADL record for 10/17/14 through 12/08/14 found Resident #132 was only showered on 11/10/14. The ADL record indicated Resident #132 had refused a shower on 11/6/14, 11/13/14, 11/20/14, 12/01/14, 12/04/14, and 12/08/14. Therefore, Resident #132 was only showered one (1) time on 11/10/14 during this time frame. The facility did offer showers on six (6) other occasions which the resident refused. Resident #132 was not showered, or offered a shower, on the remaining seven (7) scheduled shower days. The documented refusals on 11/13/14 and 12/01/14 indicated the resident had requested to have a shower in the morning (11/14/14 and 12/02/14). There was no evidence the staff offered to shower Resident #132 on the morning of 11/14/14 and 12/02/14. 4. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/22/14 when she was discharged back to the hospital. Between 12/11/14 and 12/22/14 Resident #132 was scheduled to receive a shower on 12/15/14 and 12/18/14. A review of Resident #132's ADL record for 12/11/14 through 12/22/14 revealed Resident #132 refused both showers which were scheduled during this time frame. Documentation indicated Resident #132 refused her shower on 12/18/14 because she had been out of the facility to a doctor appointment and did not feel like taking a shower. There was no evidence to support facility staff offered to shower Resident #132 on any other days during this time frame. 5. Resident #132 was readmitted from the hospital to the facility on [DATE] and had no other discharges at the time of this review. Between 12/30/14 and 01/22/14 (the time this review was conducted) Resident #132 was scheduled to receive a shower on 12/31/14, 01/03/14, 01/07/14, 01/10/14, 01/13/14, and 01/17/14. A review of Resident #132's ADL record for 12/30/14 through 01/22/14 found Resident #132 received a shower on 01/13/14. There were no documented refusals of showers during this time frame. Therefore, Resident #132 received and/or was offered one (1) of her six (6) scheduled showers. 6. The Director of Nursing (DON) was interviewed at 1:43 p.m. on 01/26/15. She confirmed all resident showers should be documented on the ADL record. She was asked to review the ADL record for Resident #132 since the date of admission on 09/23/14. The DON reviewed the ADL record and confirmed Resident #132 was not receiving her showers as scheduled. She indicated she would have the staff give her a shower today. The DON stated if a resident refused a shower and requested one to be given the next day, the nurse aides should honor that request. She stated the schedule was something the staff went by, but if a resident requested a shower on a different day, the nurse aides were expected to honor the resident's request. b) Resident #75During Stage 1 of the Quality Indicator Survey, at 1:47 p.m. on 01/19/15, the resident was asked, Do you choose how many times a week you take a bath or shower? The resident replied, They don't tell me when I am getting a shower. I am supposed to get two (2) a week, but I don't know when they are scheduled. Review of the shower schedule on 01/21/15 at 11:30 a.m., revealed Resident #75 was scheduled to receive showers on Tuesdays and Fridays on the 7-3 shift. Interview with the Director of Nursing (DON) on 01/26/15 at 10:40 a.m., indicated the ADL record was the official documentation as to whether or not the resident has had a shower or not. On 01/26/14 at 11:00 a.m., a review of the Activities of Daily Living (ADL) Record revealed in (MONTH) 2014, the resident had received three (3) of nine (9) scheduled showers. In (MONTH) (YEAR), the resident received three (3) of seven (7) scheduled showers. An interview on 01/26/15 at 1:45 p.m. with the DON, confirmed Resident #75 had not received her showers as scheduled. | 2018-08-01 |
| 5696 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 246 | D | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility failed to provide a reasonable accommodation of individual needs for one (1) of forty (40) sampled residents observed during Stage 1 of the survey process. The call bell for a resident who was in bed, was lying on the floor out of reach under the bed. Resident identifier: #105. Facility census: 108. Findings include: a) Resident #105 An observation on 01/20/15 at 9:00 a.m., revealed the call bell for Resident #105 lying on the floor beneath the resident's bed. At 9:05 a.m. on 01/20/15, upon inquiry, Licensed Practical Nurse (LPN) #23, said the resident was able to make his needs known and to communicate well with the nurse aides. In an interview on 01/20/15 at 9:10 a.m., Nurse Aide (NA) #91 said Resident #105 was able to make his needs known, and was capable of using his call bell when he needed assistance. The NA was asked to observe the positioning of the call bell for Resident #105. The NA entered the resident's room, observed the call bell lying beneath the resident's bed, and promptly secured the call bell within the resident's reach. She verified the call bell should always be secured within reach of the resident. | 2018-08-01 |
| 5697 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 272 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument Manual, and staff interview, the facility failed to accurately complete comprehensive minimum data (MDS) assessments for three (3) of nineteen (19) residents whose MDSs were reviewed. The MDS for dental status was not accurate for Resident #137. The MDS in the area of skin conditions (pressure ulcers) was not accurate for Resident #75. The MDS was not accurate for Resident #132 in the area of medications. Resident identifiers: #137, #75, and #132. Facility census: 108. Findings include: a) Resident #137 Observation of the resident's oral cavity during an interview in Stage 1 of the Quality Indicator Survey (QIS), at 9:27 a.m. on 01/20/15, found he had discolored, broken, and missing teeth. When asked if he had problems with his teeth, the resident replied, Yes, my teeth are falling out just like an old horse. Review of the annual MDS with an assessment reference date (ARD) of 07/01/14 found Section (L), entitled oral/dental status, identified the resident as having no obvious cavity or broken natural teeth (L0200). At 4:45 p.m. on 01/20/15, the MDS coordinator, Employee #22, examined the resident's oral cavity. She confirmed the resident had discolored and missing teeth. Observation of the teeth on the bottom left revealed several teeth were black and broken at the gum line. She said she had not completed the oral exam herself, but relied on nursing documentation to complete the MDS. An annual nursing assessment completed on 07/01/14 revealed the nurse completing the assessment had checked the teeth located on the upper right, lower right, and lower left were all in poor condition. At 9:15 a.m. on 01/21/15, the director of nursing stated the annual MDS did not capture the resident's dental problems. The director of nursing said the facility would correct this MDS assessment. b) Resident #75 On 01/26/15 at 2:30, a review of Resident #75's admission nursing assessment dated [DATE], revealed the resident had an old surgical scar on the right knee. The medical record revealed two (2) significant change minimum data set (MDS) assessments, with assessment reference dates (ARD) of 09/19/14 and 09/26/14. On 01/26/15 at 1:00 p.m., review of the assessments revealed Item M0100A was coded as the resident having a Stage I pressure ulcer, a scar over a bony prominence, or a non-removable dressing and/or device. Item M0150, was coded to indicate the resident was not at risk of developing a pressure ulcer. Item M0210, regarding unhealed pressure ulcers was coded as the resident not having one (1) or more unhealed pressure ulcer(s) at Stage one or higher. In an interview with MDS Nurse #20, on 01/29/15 at 3:15 p.m., she said this resident did not have a Stage I pressure ulcer, a scar over a bony prominence, or a non-removable dressing and/or device. She acknowledged the two (2) significant change MDSs were incorrectly coded. c) Resident #132 A review of Resident #132's medical record at 10:10 a.m. on 01/26/15 revealed a physician's orders [REDACTED]. A review of Resident #132's medication administration record (MAR) from 12/30/14 through 01/06/15, revealed Resident #132 received this medication daily as ordered by the physician. Further record review, found a Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/06/15, was not coded in Item N0300 - injections to indicate the resident had received injections seven (7) of the seven (7) days in the look back period. Review of the Resident Assessment Instrument (RAI), Version 3.0 Manual, found the coding instructions for N0300 were, Count the number of days that the resident received any type of injection (subcutaneous, intramuscular, or interdermal) while a resident of the nursing home. Record the number of days that any type of injection (subcutaneous, intramuscular, or interdermal) was received in Item N0300. An interview with Registered Nurse MDS Coordinator #103, at 3:32 p.m. on 01/26/15, confirmed she had inaccurately coded Item N0300. She reviewed the MAR and stated, I must have made a data entry error. She confirmed item N0300 was coded as 0 and should have been coded as 7. | 2018-08-01 |
| 5698 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 278 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional(s) who completed and certified the accuracy of portions of the minimum data set (MDS) assessments for two (2) of nineteen (19) sampled residents, failed to ensure all items in the sections were accurately coded. Section M of Resident #75's and Resident #124's assessments did not accurately reflect the residents' status regarding pressure ulcers. Resident identifiers: #75 and #124. Facility census: 108. Findings include: a) Resident #75 On 01/26/15 at 2:30, a review of Resident #75's admission nursing assessment dated [DATE], revealed the resident had an old surgical scar on the right knee. The quarterly minimum data set (MDS) assessment was reviewed on 01/26/13 at 1:00 p.m. Review of Section M of the minimum data set, with an assessment reference date (ARD) of 12/18/14, found Item M0100A was coded as the resident having a Stage I or greater pressure ulcer, a scar over a bony prominence, or a non-removable dressing/device. Item M0210 addressed the risk for pressure ulcers to develop. It was coded as the resident was not at risk of developing pressure ulcers. In an interview with the MDS Nurse #20, on 01/29/15 at 3:15 p.m., she said this resident did not have a Stage I or greater pressure ulcer, a scar over a bony prominence, or a non-removable dressing/device. She acknowledged the quarterly MDS was incorrectly coded. b) Resident #124 On 01/20/15 at 4:30 p.m., review of the resident's medical record revealed [REDACTED]. In Section M, Skin Conditions, Item M0300, addressing the current number of unhealed pressure ulcers at each stage, identified the resident had one (1) Stage II pressure ulcer. However, Item M0100, was not checked to indicate the resident had a Stage I or greater pressure ulcer. On 01/20/15 at 5:25 p.m., MDS Nurse #22, upon review of the resident's MDS assessment, verified Resident #124 had a Stage II pressure ulcer at the time the assessment had been completed, and Item M0100 should have been checked. At 9:00 a.m. on 01/22/15, Employee #22 provided a copy of the corrected MDS assessment with an ARD of 11/03/14, indicating in section M0100, the resident had a Stage I or greater pressure ulcer at the time of the assessment. | 2018-08-01 |
| 5699 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 279 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to meet the assessed needs of three (3) of nineteen (19) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey (QIS). Resident #93's care plan did not address the resident's activity goals, preferences or special needs related to activities. Resident #124 had an actual pressure ulcer, which was not addressed on her comprehensive care plan. Additionally, Resident #74's urinary incontinence status was not addressed on her comprehensive care plan. Resident identifiers: #93, #124, and #74. Facility census: 108. Findings include: a) Resident #93 A review of Resident #93's medical record on 01/28/15 at 9:25 a.m., revealed a recreation assessment dated [DATE]. This assessment indicated the following summary and goals for Resident #93 (typed as written), Resident is alert and able to voice needs with some confusion. Speech is clear. Vision impaired needs large print. Up in w/c (wheelchair) and transported by staff. She is friendly and likes to talk. Activities of interests are bingo, church, parties, and socials. Activities calendar provided and invited to attend activities. Material offered for self-directed activities. A review of Resident #93's care plan revealed no focus, goals or interventions pertaining to the resident's activities interests, need for large-print items, or her activity goals. The facility identified these activities of interest in the recreation assessment dated [DATE]. An interview with the Certified Activity Director (CAD) at 9:49 a.m. on 01/28/15, confirmed the care plan did not address Resident #93's activity goals, which the facility identified in the recreational assessment dated [DATE]. She stated she usually wrote a care plan for every resident, but must have missed Resident #93. b) Resident # 124 During a review of the care plan for Resident #124, on 01/21/15 at 8:20 a.m., a focus area with goals and interventions was identified. The focus area identified the resident as at risk for skin breakdown as evidenced by a Stage II pressure ulcer to the right upper buttock and decreased mobility and fragility of the skin. The goal in the focus area stated, The resident will not show any signs of skin breakdown daily through next quarterly review period. The facility initiated the focus area and goal on 10/14/14. During a review of the care plan for Resident #124 with the director of nursing (DON) on 01/21/15 at 1:20 p.m., she verified the goal stating the resident would not show any signs of skin breakdown was not a realistic goal. She went on to verify this goal was not appropriate since the focus area stated the resident had a Stage II pressure ulcer. She said the goal should have stated, The resident will not show any further signs of skin breakdown. c) Resident #74 Resident #74 came to the facility on [DATE]. A review of the current care plan, created on 11/20/14 and revised on 12/17/14, found a problem addressing urinary incontinence: Resident is incontinent of urine and is unable to cognitively or physically participate in a retraining program. The goals associated with this problem were Resident will be clean, dry, and odor free daily. Resident will be free from skin irritation or breakdown due to incontinence through next quarterly review. A significant change minimum data set (MDS) with an assessment reference date (ARD) of 12/23/14 identified the resident was always incontinent of urine (no episodes of continent voiding) in Item H0300. Further review of the MDS found the resident scored a 14 on the Brief Interview for Mental Status (BIMS), Section (C), entitled Cognitive Patterns (C0500). A score of 13-15 on the BIMS indicated the resident was cognitively intact. Section (G) entitled, physical functioning (G0110) found the resident required the extensive assistance of one (1) staff member for toileting. The facility did not develop the current care plan based on the MDS. According to the MDS, the resident could cognitively and physically, with staff assistance, participate in a retraining program. A three-day bowel and bladder continence evaluation began 12/16/14 at 5:00 p.m. and ended on 12/19/14 at 5:00 p.m. The evaluation was to be completed by checking the following: - The type of incontinence: functional, mixed, overflow, stress, transient, or urge. - The type of program and stated reason for choice: A restorative program with bladder re-training or prompted voiding, or scheduled voiding, or check and change. -The last step required documentation of interventions on the resident's care plan and nursing assistant care card as applicable. This information was not completed on the evaluation. The facility failed to identify the type of incontinence and the type of program chosen to address the incontinence. At 8:48 a.m. on 01/22/15, the issues with the current care plan were discussed with the administrator and the registered nurse MDS coordinator, Employee #22. At 1:30 p.m. on 01/22/15, the director of nursing (DON) provided the following documents and highlighted the following areas on the documents: - A nursing assessment was completed on 11/11/14. Section (4b) was highlighted and coded the resident as occasionally incontinent of urine. The current toileting methods were use of the bathroom and bedpan. - A nursing assessment completed on 12/16/14 revealed Section (4b) was highlighted noting the resident was incontinent of urine, and the onset was not new. - A urinary incontinence evaluation, dated 12/19/14, noted there were no clinical factors contributing to the urinary incontinence, no [MEDICAL CONDITION] causes, and no restrictions such as mobility, vision and no intestinal elimination causes for the urinary incontinence. The information provided by the DON did not suggest the resident was unable participate in a retraining program. At the close of the survey on 01/29/15, the facility had provided no further information. | 2018-08-01 |
| 5700 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 280 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to re-evaluate and revise the comprehensive care plans for two (2) of nineteen (19) residents whose care plans were reviewed, when the residents' status changed. Resident #74's care plan was not revised when her activity preferences changed. Resident #122's care plan was not revised when her pain medication was discontinued. Resident identifiers: #74 and #122. Facility census: 108. Findings include: a) Resident #74 Review of the resident's medical record found the resident came to the facility on [DATE]. A recreational assessment, completed on 11/11/14, listed the resident's religion as Methodist. According to the assessment, it was very important for the resident to participate in religious services. An activities care plan, developed on 11/17/14, identified a problem of, Resident would benefit from opportunities to make decisions/choices related for self-directed or group involvement in meaningful activities. Prefers to remain in room at this time. The goal associated with this problem was, Resident will plan and choose to engage in preferred group activities enjoys bingo and church or in room self-directed activities through next review. On 12/22/14, the facility created a new recreational assessment for this resident. The assessment listed the resident's religion as Christian. The assessment also indicated the resident did not consider it important to attend religions services. The facility did not revise the current care plan when the resident no longer expressed an interest in attending church services. In an interview at 2:00 p.m. on 01/21/15, the activity director, Employee #38, confirmed she had interviewed the resident on 12/22/14 and the resident had stated it was not important at all for her to participate in religious activities. b) Resident #122 A review of Resident #122's care plan at 10:14 a.m. on 01/28/15, revealed a focus of (typed as written), PAIN: Resident exhibits or is at risk for alterations in comfort related to receiving hospice services r/t (related to) end of life care for end stage [MEDICAL CONDITIONS]. The care plan interventions related to this focus included, (typed as written), Administer PRN (as needed) pain medication per MD (Medical Doctor) orders and note effectiveness. Notify MD if pain is not reduced: [MEDICATION NAME]. Review of Resident #122's current physician's orders [REDACTED]. Resident #122's PRN [MEDICATION NAME] and his PRN [MEDICATION NAME] were discontinued on 10/31/14. An interview with the Assistant Director of Nursing (ADON) at 11:07 a.m. on 01/28/15, confirmed Resident #122's care plan interventions related to pain management should have been revised when the PRN [MEDICATION NAME] and [MEDICATION NAME] were discontinued on 10/31/14. She confirmed Resident #122's care plan still indicated Resident #122 had an order for [REDACTED].> | 2018-08-01 |
| 5701 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 282 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to implement the interventions established in care plans for four (4) of nineteen (19) residents whose care plans were reviewed in Stage 2 of the survey. Resident #75 and Resident #132 did not receive showers as directed by the care plan. Resident #54 did not have her vital signs taken before and after her [MEDICAL TREATMENT] treatments as directed by the care plan. Resident #137 did not have interventions implemented in accordance with his care plan when the resident refused care. Resident identifiers: #75, #54, #137, and #132. Facility census: 108. Findings include: a) Resident #75 During Stage 1 of the Quality Indicator Survey, at 1:47 p.m. on 01/19/15, the resident was asked, Do you choose how many times a week you take a bath or shower? The resident replied, They don't tell me when I am getting a shower. I am supposed to get two (2) a week, but I don't know when they are scheduled. Medical record review revealed Resident # 75 was scheduled to receive showers twice a week on Tuesdays and Friday on the 7-3 shift. Review of the care plan identified the resident had a self-care deficit related to cognitive impairment, muscle weakness, visual impairment, and shortness of breath at times. The goal regarding this was for the resident to continue to participate in activities of daily living (ADLs), continue to be independent to supervision only with ADL functions and to have a neat, clean well groomed appearance, be appropriately dressed, be odor free, and needs met daily. An intervention was, Baths and showers per schedule and when necessary (PRN). Skin checks, shower, shampoo hair, nail care and lotion PRN. Review of the medical record for (MONTH) 2014, found the resident did not receive showers on six (6) of nine (9) scheduled days as directed by the care plan. Review of the (MONTH) (YEAR) documentation found the resident did not receive a shower on four (4) of seven (7) scheduled days as directed by the care plan. An interview on 01/26/15 at 1:45 p.m., with the DON, confirmed Resident #75 had not received her showers as directed by the care plan. She verified there were six (6) days in (MONTH) 2014 and four (4) days in (MONTH) (YEAR) this resident was not showered as directed in her care plan. b) Resident #54 Medical record review on 01/27/15 revealed Resident #54 had a [DIAGNOSES REDACTED]. Review of the care plan identified the resident currently receiving [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. The goal was resident will attend [MEDICAL TREATMENT] per schedule. An intervention was, Vital signs prior to and after [MEDICAL TREATMENT]. Review of thirty-two (32) [MEDICAL TREATMENT] communication forms dated 11/01/14 to 01/20/15 found the resident's pre and post [MEDICAL TREATMENT] vital signs and other information were not recorded by the facility on twenty-six (26) of the thirty-two (32) days: 11/01/14, 11/04/14, 11/06/14, 11/08/14, 11/11/14, 11/13/14, 11/15/14, 11/18/14, 11/20/14, 11/25/14, 11/26/14, 11/29/14, 12/02/14, 12/06/14, 12/09/14, 12/13/14 12/16/14, 12/18/14, 12/20/14, 12/27/14, 12/29/14, 01/08/15, 01/10/15, 01/13/15, 01/15/15, and 01/17/15. An interview on 01/26/15 at 1:45 p.m. with the DON, confirmed Resident #54 had not had her vital signs taken before and after [MEDICAL TREATMENT] as directed by the care plan. She verified there were 26 of 32 [MEDICAL TREATMENT] days that the resident's vital signs were not obtained as directed in her care plan. c) Resident #137 Observation of the resident during Stage 1 of the Quality Indicator Survey (QIS) at 9:27 a.m. on 01/20/15, found the resident's fingernails were long and dirty, his hair was uncombed, and his face was unshaven. Pieces of egg, served at breakfast, littered the resident's facial hairs, shirt, and bed sheets. At 4:45 p.m. on 01/20/15, the resident remained in the same condition as the 9:27 a.m. observation. At 8:20 a.m. on 01/21/15, the resident was still wearing the same egg stained shirt as the day before and his hygiene had not changed. Employee #32, the resident's nursing assistant was asked why the resident was still wearing the same clothes as the day before, and why he had not been cleaned up. She stated she had tried, but the resident refused care. She said, He wants to do it himself. Review of the nursing assistant activities of daily living (ADL) record found the resident had refused assistance with personal hygiene daily from 01/05/15 to 01/21/15. He had refused to accept assistance with dressing and bathing. At 9:15 a.m. on 01/21/15, the director of nursing (DON) stated the resident refused personal care and he would not let the staff put clean clothes on him. She stated the resident had capacity and could refuse care, which the facility had documented on the care plan. Review of the resident's current care plan, revised on 09/17/14, found the problem: Resident exhibits behavior: resists care or treatment as noted by cursing, yelling at staff, refusal of medications, labs and to be cleaned up, have clothes changed, keeps personal belongings on the floor etc. Combative and has struck CNA (certified nursing assistant) staff in the past as well as swung at lab tech. (technician). The goal associated with this problem was, Resident will have no behaviors as noted by no episodes of cursing/threatening staff or attempting to hit staff during care or refusing care including ADLs medications and meals 4 out of 7 days per week thru next review. Interventions associated with the problem and goal included: -- Divert resident by giving alternative objects or activity, -- Document interventions and resident's response, -- If resident refuses care, leave resident and return in 5-10 minutes and re-attempt. Do not argue with resident, advise residents staff nurse of refusals, -- Listen to resident's needs and adjust plan as appropriate, Notify social services with behaviors. At 11:30 a.m. on 01/22/15, the social services director, Employee #128, the author of the care plan indicated she would look for supporting documentation to show the implementation of the care plan interventions. She said she would return later with the information. At 2:00 p.m. on 01/22/15, Employee #128 said she had read the nurses' notes and could not find anything to support the interventions taken when the resident had refused care. d) Resident #132 1. At 2:00 p.m. on 01/19/15, Resident #132 was asked if she was able to choose how many times a week she took a bath or shower. She replied, No I have only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it the previous week, but it did not do any good because she still had not received a shower. Observations of Resident #132 made at this time revealed her hair appeared to be unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15 revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14, Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14 and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 received a shower on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this period. 3. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/09/14 when she was discharged back to the hospital. Between 10/17/14 and 12/09/14 Resident #132 was scheduled to receive a shower on 10/20/14, 10/23/14, 10/27/14, 10/30/14, 11/03/14, 11/06/14, 11/10/14, 11/13/14, 11/17/14, 11/20/14, 11/24/14, 11/27/14, 12/01/14, 12/04/14, and 12/08/14. A review of Resident #132's ADL record for 10/17/14 through 12/08/14 found Resident #132 only received a shower on 11/10/14. The ADL record indicated Resident #132 had refused a shower on 11/6/14, 11/13/14, 11/20/14, 12/01/14, 12/04/14, and 12/08/14. Therefore, Resident #132 only received one (1) shower, on 11/10/14, during this period. The facility did offer showers on six (6) other occasions, which the resident refused. Resident #132 was not showered, nor offered a shower on the remaining seven (7) scheduled shower days. The documented refusals on 11/13/14 and 12/01/14 indicated the resident had requested to have a shower in the morning (11/14/14 and 12/02/14) there was no evidence the staff offered to shower Resident #132 on the morning of 11/14/14 and 12/02/14. 4. Resident #132 came back from the hospital to the facility on [DATE]. She remained at the facility until 12/22/14 when she went back to the hospital. Between 12/11/14 and 12/22/14, the facility scheduled Resident #132 to receive a shower on 12/15/14 and 12/18/14. A review of Resident #132's ADL record for 12/11/14 through 12/22/14 revealed Resident #132 refused both scheduled showers during this period. Documentation indicated Resident #132 refused her shower on 12/18/14 because she had been out of the facility to a doctor appointment and did not feel like taking a shower. There was no evidence to support facility staff offered to shower Resident #132 on any other days during this period. 5. Resident #132 returned to the facility from the hospital on [DATE] and had no other discharges at the time of this review. Between 12/30/14 and 01/22/14, the time this review was conducted Resident #132 was scheduled to receive a shower on 12/31/14, 01/03/14, 01/07/14, 01/10/14, 01/13/14, and 01/17/14. A review of Resident #132's ADL record for 12/30/14 through 01/22/14 found Resident #132 received a shower on 01/13/14. There were no documented refusals of showers during this period. Therefore, Resident #132 received and/or was offered one (1) of her six (6) scheduled showers. 6. A review of Resident #132's care plan revealed the following focus (typed as written): Self-care deficit r/t (related to) recent hospital stay . The goal for this focus was (typed as written): Resident will be clean, dry and well groomed through next quarterly review. One (1) of multiple interventions listed to help achieve this goal was (typed as written): Bed baths daily with showers 2 x's (times) a week and PRN (as needed). Shave and nail care PRN. This intervention had a creation date of 10/02/14. With Resident #132's most recent admitted , being the date this goal was last initiated. 7. The Director of Nursing (DON), in an interview at 1:43 p.m. on 01/26/15, confirmed all resident showers should be documented on the ADL record. The DON reviewed the ADL record for Resident #132 since the resident's admission date of [DATE]. The DON confirmed Resident #132 did not receive her showers as scheduled. She indicated she would have the staff give her a shower today. The DON stated if a resident refused a shower and requested one the next day, the nurse aides should honor that request. She stated the schedule was something the staff went by, but if a resident requested a shower on a different day, the nurse aides were to honor the residents' request. The DON was asked to review Resident #132's care plan related to her self-care deficit. After she had completed reviewing the care plan, the DON confirmed the intervention pertaining to showers was not implemented because Resident #132 was not showered or offered a shower twice weekly during her stay at the facility. | 2018-08-01 |
| 5702 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 309 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey (QIS) received care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. The facility failed to ensure Resident #54, who received [MEDICAL TREATMENT], was assessed at the nursing facility before and after [MEDICAL TREATMENT]. In addition, the facility failed to correlate the resident's care with the [MEDICAL TREATMENT] center and failed to follow facility policy for care of a resident receiving [MEDICAL TREATMENT]. Resident identifier: #54. Facility Census: 108. Findings include: a) Resident #54 Medical record review found the resident was receiving [MEDICAL TREATMENT] via an arteriovenous (AV) fistula in the left arm three (3) days a week, on Tuesdays, Thursdays and Saturdays, at an offsite [MEDICAL TREATMENT] center. The resident had resided at the facility since 07/28/14 and had been receiving [MEDICAL TREATMENT] since admission.The medical record contained copies of a [MEDICAL TREATMENT] communication record, shared by the facility and the [MEDICAL TREATMENT] center. The facility was to complete the top half of the form, which included the resident's vital signs before the resident left the facility for [MEDICAL TREATMENT], an examination of the shunt site, the time of the resident's last meal, medication given prior to [MEDICAL TREATMENT], the resident's general condition, and special instructions. The [MEDICAL TREATMENT] center was to complete the bottom half of the form which also included obtaining vital signs, lab work done, medications given, intake and output, monitoring the shunt site for location, the condition of the dressing, ports, pain and any other pertinent information.Neither the facility, nor the [MEDICAL TREATMENT] center consistently recorded the resident's information pre and post [MEDICAL TREATMENT] treatments.Review of thirty-two (32) [MEDICAL TREATMENT] communication forms dated 11/01/14 to 01/20/15 found the resident's pre and post vital signs and other information were not recorded by the facility on twenty-six (26) of the thirty-two (32) days: 11/01/14, 11/04/14, 11/06/14, 11/08/14, 11/11/14, 11/13/14, 11/15/14, 11/18/14, 11/20/14, 11/25/14, 11/26/14, 11/29/14, 12/02/14, 12/06/14, 12/09/14, 12/13/14 12/16/14, 12/18/14, 12/20/14, 12/27/14, 12/29/14, 01/08/15, 01/10/15, 01/13/15, 01/15/15, and 01/17/15. On the same dates, twenty-six (26) of the thirty-two (32) [MEDICAL TREATMENT] treatment dates, the [MEDICAL TREATMENT] center failed to complete / supply any information on the [MEDICAL TREATMENT] communication record.The medical record / [MEDICAL TREATMENT] communication form contained no information regarding laboratory values obtained by the [MEDICAL TREATMENT] center.Review of the resident's current care plan, on 01/22/15 at 10:00 a.m., found a problem: Resident currently receiving [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. Potential for electrolyte imbalance and dehydration. Goals were: Labs will be within normal limits with lab tests, resident will attend [MEDICAL TREATMENT] per schedule through the next quarter and show no signs of dehydration thru next review. The approaches associated with this problem were: -- Auscultate bruit and palpate the thrill. Notify the physician of absence of bruit/thrill. -- Do not utilize [MEDICAL TREATMENT] catheter-- [MEDICAL TREATMENT] frequency: three times a week Tuesday, Thursday and Saturdays.-- [MEDICAL TREATMENT] center is (Name of the center).-- No restrictive clothing on left arm. Keep elevated on pillow every shift.-- Notify primary care physician and [MEDICAL TREATMENT] unit if there is s/s (signs/symptoms) of infection. -- Observe around [MEDICAL TREATMENT] dressing for s/s of infection such as redness, warmth, drainage and tenderness. Advise physician and [MEDICAL TREATMENT] if s/s are noted.-- No lab draws or b/p (blood pressure) in left arm.-- Observe resident for signs of pain. Administer medication as ordered. -- Obtain lab work as ordered. Notify the doctor of abnormal values. -- Send bag lunch to [MEDICAL TREATMENT] with the resident. -- Vital signs prior to and after [MEDICAL TREATMENT]. Review of the facility's policy for [MEDICAL TREATMENT] Services found the purpose of the policy was, To provide continuation of necessary care and services to those residents receiving [MEDICAL TREATMENT] from a community based [MEDICAL TREATMENT] center. It is the facility responsibility to develop a plan of care for the resident that includes a means of communication between the resident, the center and the facility staff.The policy also contained the following procedures: The facility staff will complete the [MEDICAL TREATMENT] Resident Communication Report to include the information required by the [MEDICAL TREATMENT] center prior to the resident leaving for treatment. The communication form will provide a means of useful communication between the facility and [MEDICAL TREATMENT] center. The resident care plan that includes care of the shunt / fistula, including complications, i.e. bleeding infections, etc, nutritional needs, emotional and social well being, management of [MEDICAL CONDITION] and monitoring aspects will be reviewed per the facility policy for care plan review and on as needed basis. The [MEDICAL TREATMENT] Resident Communication Report will be completed by the licensed nurse prior to the resident transfer. Upon return from the [MEDICAL TREATMENT] center, the resident will be evaluated by the licensed nurse including vital signs, shunt / fistula observation and the results of the evaluation will be documented in the medical record Essential points / required elements: .A completed communication sheet.- What meals, nutritional supplements or snacks should be sent with the resident.- What documentation items should be returned with the resident from the [MEDICAL TREATMENT] center, if more that the completed communication form.- Need to have a contact number and emergency contact for a nurse at the [MEDICAL TREATMENT] center clearly posted and / or included in the resident's medical record. Essential points / required elements: - There needs to be staff education on [MEDICAL CONDITION] and [MEDICAL TREATMENT] complications, documentation, care planning and management.- Licensed staff needs to know what to do in case of an emergency.On 01/28/15 at 2:30 p.m., during an interview with the director of nursing (DON), she agreed the [MEDICAL TREATMENT] center should supply the facility with pre and post weights. She said she did not know what laboratory values the [MEDICAL TREATMENT] center should obtain. She also agreed there should be better communication between the facility and the [MEDICAL TREATMENT] center. The DON also agreed the resident's care plan did not include who would weigh the resident pre and post [MEDICAL TREATMENT], the telephone number and the [MEDICAL TREATMENT] contact person. | 2018-08-01 |
| 5703 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 312 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) without staff assistance, received the necessary care and services to maintain good grooming and personal hygiene. Resident #132 was only provided a shower and/or offered a shower on multiple occasions. On occasion, she refused when offered, but asked to be showered the following morning. There was no evidence that upon these refusals the facility staff offered and/or provided a shower the following morning. One (1) of five (5) residents reviewed for Activities of Daily Living, Cleanliness and Grooming were affected. Resident Identifier: #132. Facility Census: 108. Findings Include: a) Resident #132 1. At 2:00 p.m. on 01/19/15 Resident #132 was asked if she was given the opportunity to choose how many times a week she took a bath or shower, she replied, No I have only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it last week, but it did not do any good because she has still not received a shower. Observations of Resident #132 made at this time noted her hair was unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15 revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14 Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14 and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 was only showered on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this time frame. Further record review found an Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/30/14, which indicated Resident #132 was totally dependent on staff for bathing. An additional fourteen (14)-Day MDS with and ARD of 10/07/14 indicated Resident #132 required physical help from staff during part of the bathing activity. Both MDSs indicated Resident #132 was unable to perform the bathing process independently during this time frame. 3. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/09/14 when she was discharged back to the hospital. Between 10/17/14 and 12/09/14 Resident #132 was scheduled to receive a shower on 10/20/14, 10/23/14, 10/27/14, 10/30/14, 11/03/14, 11/06/14, 11/10/14, 11/13/14, 11/17/14, 11/20/14, 11/24/14, 11/27/14, 12/01/14, 12/04/14, and 12/08/14. A review of Resident #132's ADL record for 10/17/14 through 12/08/14 found Resident #132 was only showered on 11/10/14. The ADL record indicated Resident #132 had refused a shower on 11/6/14, 11/13/14, 11/20/14, 12/01/14, 12/04/14, and 12/08/14. Therefore, Resident #132 was only showered one (1) time on 11/10/14 during this time frame. The facility did offer showers on six (6) other occasions which the resident refused. Resident #132 was not showered nor offered a shower on the remaining seven (7) scheduled shower days. The documented refusals on 11/13/14 and 12/01/14 indicated the resident had requested to have a shower in the morning (11/14/14 and 12/02/14) there was no evidence the staff offered to shower Resident #132 on the morning of 11/14/14 and 12/02/14. Further review of Resident #132's medical record found a 5-day MDS with and ARD of 10/24/14 and a 14-day MDS with an ARD of 10/31/14. Both MDSs indicated Resident #132 was totally dependent on staff for bathing. An additional 30-day MDS completed during this time frame with an ARD of 11/14/14 indicated Resident #132 required physical help from staff with at least part of the bathing process. Therefore, all three (3) MDSs indicated Resident #132 was unable to perform the bathing process independently during this time frame. 4. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/22/14 when she was discharged back to the hospital. Between 12/11/14 and 12/22/14 Resident #132 was scheduled to receive a shower on 12/15/14 and 12/18/14. A review of Resident #132's ADL record for 12/11/14 through 12/22/14 revealed Resident #132 refused both showers which were scheduled during this time frame. Documentation indicated Resident #132 refused her shower on 12/18/14 because she had been out of the facility to a doctors appointment and did not feel like taking a shower. There was no evidence to support staff offered to shower Resident #132 on any other days during this time frame. An additional review of the medical record found a Significant Change MDS with and ARD of 12/18/14 which indicated Resident #132 required physical help in part of the bathing activity and was unable to perform the task independently. 5. Resident #132 was readmitted from the hospital to the facility on [DATE] and had not other discharges at the time of this review. Between 12/30/14 and 01/22/14 the time this review was conducted Resident #132 was scheduled to receive a shower on 12/31/14, 01/03/14, 01/07/14, 01/10/14, 01/13/14, and 01/17/14. A review of Resident #132's ADL record for 12/30/14 through 01/22/14 found Resident #132 received a shower on 01/13/14. There were no documented refusals of showers during this time frame. Therefore, Resident #132 received and/or was offered one (1) of her six (6) scheduled showers. Further review of Resident #132's medical record found a Significant Change MDS with an ARD of 01/06/15 which indicated Resident #132 required physical help in part of the bathing activity and was unable to perform the task independently. 6. The Director of Nursing (DON) was interviewed at 1:43 a.m. on 01/26/15, confirmed all resident showers should be documented on the ADL record. She was asked to review the ADL record for Resident #132 since he date of admission on 09/23/14. The DON reviewed the ADL record and confirmed Resident #132 was not receiving her showers as scheduled. She indicated she would have the staff give her a shower today. The DON stated if a resident refused a shower and requested one to be given the next day, the nurse aides should honor that request. She stated the schedule was something the staff went by, but if a resident requested as shower on a different day, the nurse aides were expected to honor the resident's request. | 2018-08-01 |
| 5704 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 315 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure a resident, who had a decline in bladder functioning shortly after admission to the facility, received a thorough assessment to determine if any services could be provided to restore or improve bladder functioning. The facility completed a three-day voiding diary but did not identify the type of incontinence present and did not determine if the resident could benefit from a toileting program to restore or improve the resident's urinary incontinence. This was true for one (1) of three (3) residents reviewed for the care area of urinary incontinence during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #74. Facility census: 108. Findings include: a) Resident #74 Resident #74 was admitted to the facility on [DATE]. Review of admission minimum data set (MDS) with an assessment reference date (ARD) of 11/11/14, found Section H - Urinary Incontinence, Item H0300 identified the resident as being frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). A significant change MDS with an ARD of 12/23/14 indicated the resident was always incontinent of urine (no episodes of continent voiding) in Item H0300. A three-day Bowel and Bladder Continence Evaluation was completed from 6:00 p.m. on 12/16/14 through 5:00 p.m. on 12/19/14. The evaluation was to be completed by checking the following: - The type of incontinence: functional, mixed, overflow, stress, transient, and urge. - The type of program and state reason for choice: A restorative program with bladder re-training or prompted voiding, or scheduled voiding, or check and change. - The last step required documentation of interventions on the resident's care plan and nursing assistant care card as applicable. This information had not been completed on the evaluation. The facility failed to identify the type of incontinence and the type of program chosen to address the incontinence. Review of the care plan, created on 11/20/14 and revised on 12/17/14, found a problem addressing urinary incontinence: Resident is incontinent of urine and is unable to cognitively or physically participate in a retraining program. The significant change MDS with an ARD of 12/23/14 identified the resident scored a 14 on the Brief Interview for Mental Status (BIMS), Item C0500, entitled Cognitive Patterns. (A score of 13-15 on a BIMS indicates the resident is cognitively intact.) The BIMS score did not correlate with the care plan problem indicating the resident was cognitively unable to participate in a retraining program. The significant change MDS with an ARD of 12/23/14, identified the resident required the extensive assistance of one person for toileting in Section G - Physical Functioning (G0110). The information on the MDS did not suggest the resident would be physically unable to participate in a retraining program. At 1:30 p.m. on 01/22/15, the director of nursing (DON) was asked how the facility attempted to prevent the decline in the resident's urinary continence as the resident entered the facility frequently incontinent of urine and then declined to always incontinent of urine in less than 60 days. The DON provided the following documents and highlighted the following areas: - A nursing assessment, completed on 11/11/14. Section (4b) was highlighted and coded the resident as occasionally incontinent of urine. The current toileting methods were use of the bathroom and bedpan. - A nursing assessment, completed on 12/16/14. Section (4b) was highlighted noting the resident was incontinent of urine and the onset was not new. - A urinary incontinence evaluation, dated 12/19/14, which noted there were no clinical factors contributing to the urinary incontinence, no [MEDICAL CONDITION] causes, no restrictions such as mobility, vision and no intestinal elimination causes for the urinary incontinence. The information provided by the DON did not suggest the resident could not benefit from a toileting program. Review of the facility's policy for Continence Management found, .Identify patient's continence status and need for management by reviewing the nursing assessment. If the patient is incontinent,: Complete Urinary Incontinence Assessment and/or Bowel Retraining Assessment, Address transient causes for incontinence In an interview at 10:05 a.m. on 01/27/15, the DON and Employee #22, the registered nurse MDS coordinator, both confirmed the Bowel and Bladder Continence Evaluation had not been completed according to the directions on the evaluation and the resident had not been provided services to attempt to restore or improve normal bladder functioning to the extent possible. | 2018-08-01 |
| 5705 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 323 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to provide a resident environment, in which the facility had control over, that was as free from accident hazards as possible. Resident #132 had multiple falls while a resident at the facility. Resident #132 often self-ambulated in her room with assistance from her walker. The facility put in place a fall mat at her bedside, which caused Resident #132 to experience a fall. This was true for one (1) of three (3) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident identifier: #132. Facility census: 108. a) Resident #132 An observation of Resident #132 at 2:00 p.m. on 01/19/15, revealed a Band-Aid just above her left eye. When asked what had happened to her forehead, Resident #132 stated, I got up to go to the bathroom and they had one of them rugs down and it caused me to fall and hit my head. She further stated, They took it out of here after I fell because it caused me to fall. Review of facility records at 4:00 p.m. on 01/20/15, revealed an incident/accident report for Resident #132 dated 01/15/15. The circumstances of the event were described as follows, Resident was witnessed falling in front of sink. Resident was ambulating with walker without assistance to restroom and fell . Resident hit head on floor causing a superficial laceration above the left eye . The incident/accident report also indicated the immediate actions taken to the safeguard the resident were (typed as written), Skin and Pain evaluation first aid applied to laceration above left eye. DC (discontinue) fall mats, encourage resident to ask for assistance and use call light. A review of Resident #132's medical record at 4:20 p.m. on 01/20/15, revealed a physician's orders [REDACTED].#132's bed. A review of Resident #132's activities of daily living record for the dates of 12/30/14 through 01/15/15 revealed resident was independent with walking in her room daily beginning on 01/08/15. Further review of Resident #132's medical record found a physician's orders [REDACTED].#132's bedside. The medical record also contained a nursing progress note dated 01/16/15, which contained the following text (typed as written): bed and chair alarm being utilized and fall mat to floor by bed has been discontinued as it poses a greater risk for fall. An interview with the Director of Nursing (DON) at 4:00 p.m. on 01/21/15, confirmed fall mats to the resident's bedside were not an appropriate fall intervention when the resident was able to ambulate with or without a walker. She stated they evaluated Resident #132's ability to ambulate after her fall on 01/15/15 and discontinued the fall mats. The DON was asked why the fall mats were not discontinued prior to Resident #132 falling. She stated, We may not have known she was ambulating in her room with her walker prior to this date. The DON reviewed Resident #132's ADL flow sheet for the month of (MONTH) (YEAR). She agreed the resident was independent with walking in her room daily beginning on 01/08/15, which was eight (8) days prior to the resident's fall on 01/15/15. The DON agreed the fall mat was not an appropriate intervention for Resident #132 since she could ambulate in her room. She agreed fall mats for residents who were able to ambulate posed a greater risk for falls and should not be used. | 2018-08-01 |
| 5706 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 329 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. One (1) resident (#54) identified through random opportunity for discovery, and one (1) of ten (10) residents reviewed for unnecessary medications, were affected. Resident #54, did not have a dosage reduction of [MEDICATION NAME] ([MEDICAL CONDITION] medication) as recommended by the nephrologist when the resident was discharged from the hospital. The facility physician did not provide a clinical rationale as to why the medication was not reduced. Resident #120, reviewed for unnecessary medications received [MEDICATION NAME] after the medication had been discontinued by the physician. Resident identifiers: #54 and #120. Facility census: 108. Findings include: a) Resident #54 Medical record review for Resident #54 on 01/26/15 at 11:00 a.m., revealed a hospital discharge summary in which the nephrologist recommended decreasing the [MEDICATION NAME] to 30 milligrams (mg) until 01/10/15. Further medical record review revealed an order from the facility physician for [MEDICATION NAME] 75 mg everyday on 01/07/15. The order was for one (1) tablet of [MEDICATION NAME] to be given daily until 01/10/15. The medical record did not contain a clinical rationale from the resident's attending physician at the facility regarding why the dose of [MEDICATION NAME] was not reduced as recommended by the nephrologist upon the resident's discharge from the hospital. On 01/26/15 at 2:00 p.m., the director of nursing verified there was no clinical rationale provided by the facility's attending physician for not reducing the [MEDICATION NAME] as recommended by the nephrologist when the resident was discharged from the hospital on [DATE]. b) Resident #120 On 11/21/14, the pharmacist reviewed the resident's drug regimen and recommended the medication, [MEDICATION NAME] 20 milligrams (mg) be discontinued because the medication could be interacting with the anticoagulation medication, [MEDICATION NAME]. The pharmacist noted the resident's [MEDICATION NAME] Time and International Normalized Ratio (PT/INRs) had been elevated. The physician agreed with the recommendation and wrote an order to discontinue the medication on 12/08/14. Review of the Medication Administration Record [REDACTED]. At 11:39 a.m. on 01/27/15, the administrator and the director of nursing (DON) were made aware of these findings. Both employees were unable to provide documentation the medication was discontinued on 12/08/14 as recommended by the pharmacist and ordered by the physician. | 2018-08-01 |
| 5707 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 406 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide specialized rehabilitative services (physical therapy) for Resident #74 after the physician ordered the therapy services. This was true for one (1) of three (3) residents reviewed for the care area of rehabilitation. Resident identifier: #74. Facility census: 108. Findings include: a) Resident #74 Review of the medical record found the resident went out for a consult with a general surgeon on 01/06/15. This physician had handwritten on the consult report, Needs Physical Therapy. Upon return to the facility, the resident's attending physician also wrote an order on 01/06/15 for the resident to have physical therapy. Further review of the medical record found a nurse's note, written on 01/06/15 at 10:31 a.m., .Return from appointment with (name of the surgeon) physical therapy needed, physical therapy aware of request On the morning of 01/26/15, the director of the therapy department, Employee #46, a speech therapist, was asked when the resident was last evaluated for physical therapy. Employee #46 stated physical therapy discharged the resident from their services on 12/24/14 for refusing to participate. When asked if the therapy department had evaluated the resident since that time, she replied, No. When asked about the physician's orders [REDACTED]. The director of nursing (DON) was interviewed at 4:23 p.m. on 01/26/15. She said nursing had done their part and written an order for [REDACTED]. | 2018-08-01 |
| 5708 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 411 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, and staff interview, the facility failed to obtain dental services for one (1) of three (3) residents reviewed for the dental care area during Stage 2 of the Quality Indicator Survey. The facility staff had knowledge the resident's lower dentures were broken and subsequently became lost on or before 12/30/14, but failed to make the necessary arrangements for the resident's identified dental needs. Resident identifier: #132. Facility census: 108. Findings Include: a) Resident #132 An interview with Resident #132 at 2:08 p.m. on 01/19/15, found she was having difficulty chewing some foods because her lower dentures were missing. She stated she had her teeth from (MONTH) 2014 until her most recent readmission to the facility a few weeks ago (12/30/14). She stated while she was out to the hospital the facility staff moved her things from one room to another, and her lower dentures were lost. When asked if she had told anyone at the facility her teeth were missing, she stated, Yes I told everyone the nurse aides, the nurses, and the big boss. She indicated the facility staff told her they looked for them, but were unable to locate her dentures. When asked if anyone had offered to make her a dental appointment to see about getting a new set of dentures she replied, No one has offered to do anything to help get them replaced. At 11:07 a.m. on 01/22/15, the Director of Nursing (DON) performed an oral assessment on Resident #132. The note written by the DON relating to this oral assessment contained the following text (typed as written): .Resident and family member confirmed that bottom set of dentures was later brought into the facility however was broken and glued to fit and then was dropped by the resident and re-broken and was misplaced before they could be glued for resident to wear again The DON indicated in this progress note the facility would consult Resident #132's preferred dentist for a follow up related to her missing dentures. An additional interview with Resident #132 at 12:00 p.m. on 01/22/15 revealed Resident #132's lower denture was broken before she went out to the hospital on [DATE]. She stated she had bitten into something, and the lower denture broke. She stated when she returned from the hospital on [DATE], she was going to give the lower denture to her ex-husband, so he could glue it back together as he had done in the past, and the denture was missing. Resident #132 was unable to give an exact date as to when her denture was broken. She stated, All I know is it was broken before I went to the hospital this last time. Review of Resident #132's medical record at 1:30 p.m. on 01/22/15 found Resident #132 had multiple discharges to the hospital since admission her admission to the facility. The most recent discharge to the hospital was on 12/22/14. Resident #132 was readmitted on [DATE]. Resident #132's nursing admission assessments for 10/17/14 and 12/11/14 were reviewed. The assessments revealed Resident #132 had both her upper and lower dentures present upon completion of these assessments. Review of Resident #132's nursing admission assessment dated [DATE], found the resident only had her upper dentures present when this admission assessment was completed. A review of Resident #132's care plan found the following intervention related to her self-care deficit (typed as written): Resident has upper dentures, soak QHS (every night) and PRN (as needed). (reports having lower dentures but unable to locate at this time.) The facility initiated this intervention on 12/30/14, upon Resident #132's most recent readmission to the facility. There was no evidence in the medical record to suggest Resident #132 had been referred to a dentist since her lower dentures broke, and were subsequently lost. In an interview with the DON at 3:29 p.m. on 01/22/15, when asked if Resident #132 had been referred to the dentist since her lower dentures were broken and then lost, she stated, No we did not know about it until today when you brought it to our attention. The DON was asked to review the Nursing assessment dated [DATE], and the care plan intervention dated 12/30/14. She confirmed the nurse completing the admission assessment noted the lower dentures were not present upon readmission. She also confirmed the nurse completing the care plan had knowledge the resident's dentures were missing. She confirmed staff did have knowledge of Resident #132's missing dentures, and the facility should have made an appointment prior to the discovery during the survey process. | 2018-08-01 |
| 5709 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 441 | E | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility did not maintain an infection control program which prevented, to the extent possible, the development and transmission of disease and infection. This was true for ten (10) residents who received a snack/supplement on East wing on 01/22/15. Resident #81 took the snacks and supplements out of a cooler. A staff member assisted the resident in finding his snack/supplement, then placed the snacks back into the cooler. The staff member failed to return the snack/supplements to the kitchen after they were contaminated, and they were later distributed to ten (10) separate residents. Resident identifiers: #81, #8, #147, #16, #137, #9, #74, #53, #171, #176, and #32. Facility census: 108. Findings include: a) Snack/Supplement Pass Observation An observation at 10:13 a.m. on 01/22/15 revealed Resident #81 was taking snacks and supplements out of the East wing cooler. Registered Nurse (RN) #107 (East wing unit manager) was asked if Resident #81 should be going through the snack/supplement cooler, she stated, No. RN #107 approached Resident #81 and helped him find his supplement and put the remainder of the snacks/supplements back into the cooler. At 10:22 a.m. on 01/22/15, nurse aide (NA) #71 began passing the snacks/supplements contained in the cooler. She passed a snack/supplement to Resident #8, Resident #147, Resident #16, Resident #137, Resident #9, and Resident #74. RN #107 approached NA #71, while she was passing snacks, and stated, Mr. (Resident #81's last name) was helping himself to those (referring to the snack/supplements). NA #6 also passed snacks/supplements from the cooler to Resident #53, Resident #171, and Resident #176. NA #123 also passed a supplement to Resident #32 from the cooler. An interview with the Director of Nursing at 12:30 p.m. on 01/22/15 confirmed RN #71 should have returned the snacks/supplements to the kitchen for new snacks/supplements after Resident #81 went through the cooler. She indicated the staff should not have distributed the snacks/supplements in the cooler to other residents. | 2018-08-01 |
| 5710 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 514 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of nineteen (19) medical records reviewed during Stage 2 of the Quality Indicator Survey. Resident #93's admission nursing and nutritional assessments contained an inaccurate weight. Additionally, a nursing assessment did not accurately represent Resident #93's bowel and bladder continence status. Resident identifier: #93. Facility census: 108. Findings include: a) Resident #93 1. A review of Resident #93's medical record on 01/27/15 at 9:17 a.m., revealed a nursing admission assessment dated [DATE], which indicated Resident #93 weighed 164.6 pounds. Resident #93's medical record also contained a nutrition assessment dated [DATE]. This nutrition assessment indicated the resident's weight was 164.6 pounds. Further review of Resident #93's medical record found a nursing progress note dated 12/31/14, which contained the following text (typed as written), Resident admitted to the facility with DX (diagnosis) of adult FTT (failure to thrive) and nutritional mairasmus (marasmus - a form of severe malnutrition characterized by energy deficiency) with entered into PCC (the facility's computer program) incorrectly re-weight of 99.2 (pounds) in wheelchair. Review of Resident #93's weight record indicated the weight of 164.6 pounds, which was obtained on admission was struck out by the director of nursing (DON) on 12/31/14 when a re-weight of 99.2 pounds was obtained and entered into the resident's weight record. An interview with the DON at 4:00 p.m. on 01/27/14 confirmed the weight of 164.6, recorded on the nursing admission assessment and the nutrition assessment was inaccurate. She indicated the resident only weighed 99.2 pounds on 12/31/14 and there was no way she lost that much weight in one (1) week. She indicated whoever completed her admission entered the wrong weight into the medical record. 2. A review of Resident #93's medical record on 01/27/15 at 9:17 a.m. revealed a nursing assessment dated [DATE] titled, Expanded (MDS Adm. (Minimum Data Set Admission)/Qrtly (Quarterly)/Annual/Sig. (significant) Change) v (version) 3. This assessment indicated Resident #93 was always continent of bowel and bladder. A review of Resident #93's Activities of Daily Living (ADL) flow sheet from 12/22/14 until 12/29/14 found Resident #93 was always incontinent of bowel and bladder. An interview with Registered Nurse #22, Clinical Reimbursement Coordinator at 4:15 p.m. on 01/28/25, confirmed Resident #93 had been incontinent since her admission to the facility on [DATE]. She reviewed the ADL sheets and stated Resident #93 was always incontinent. She confirmed the inaccuracy of the nursing assessment dated [DATE]. She said it did not reflect the resident's bowel and bladder status. | 2018-08-01 |
| 7077 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-08-08 | 157 | D | 1 | 0 | 16RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and interview with a resident's guardian, the facility failed to promptly notify the resident's legal representative of a change in the resident's condition for one (1) of seven (7) residents reviewed. The legal representative was not notified when Resident #115 was transferred to the hospital. Resident identifier: #115. Facility census: 113. Findings include: a) Resident #115 Review of the electronic medical record, on 08/07/14 at 8:07 a.m., revealed a nurse's note indicating Resident #115 was transferred to the hospital by ambulance on 10/24/13 for complaints of increased weakness. The minimum data set (MDS) with an assessment reference date (ARD) of 10/24/13, indicated an unplanned discharge to an acute hospital. Further review of the medical record revealed a psychiatric review, indicating the resident lacked capacity to make medical decisions. Additionally, the resident was appointed a legal guardian, who would make medical decisions on her behalf, until 11/16/13. During an interview, on 08/07/14 at 8:15 a.m., the legal guardian indicated she was not notified of the change in condition, or transfer to the hospital. Further review of the medical record, revealed no evidence the facility attempted to notify the resident's legal guardian. An interview with the director of nurses (DON) on 08/07/14 at 10:30 a.m., revealed the facility required staff to notify the medical power of attorney, guardian . of a change in condition. She indicated staff would enter a notation on the physician's orders [REDACTED]. She reviewed the medical record and confirmed no evidence was present to indicate the facility attempted to notify the legal guardian. | 2017-08-01 |
| 7078 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-08-08 | 314 | G | 1 | 0 | 16RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to ensure that a resident having pressure sores received necessary treatment and services to prevent new sores from developing for one (1) of three (3) residents reviewed with pressure ulcers. A resident developed a Stage III pressure ulcer before staff identified skin impairment. Resident identifier: #68. Facility census: 113. Findings include: a) Resident #68 An electronic medical record review, on 08/08/14 at 9:00 a.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment noted pressure ulcers (PU) on his upper mid back. Review of physician's orders [REDACTED]. They indicated a Stage II PU on his left lower back and a Stage III PU on his left hip. The Stage III pressure ulcer, in-house acquired, measuring 1.5 centimeters (cm) x 1.5 cm x 0.5 cm with 1 cm undermining/tunneling at 12:00 (12:00 indicates the anatomical position of the undermining/tunneling). Review of the pressure ulcer logs revealed the tissue around the wound was inflamed and the wound had purulent drainage. According to the resident's admission minimum data set assessment (MDS), with an assessment reference date of 05/16/14, the resident scored 15 on his Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. His [DIAGNOSES REDACTED]. According to the assessment, the resident was at risk for developing pressure ulcers and was also noted to have existing pressure ulcers. During an interview with Resident #68, on 08/08/14 at 10:00 a.m., he related he had been in the facility a few months related to a neck injury. The resident said he could move his extremities, but could not feel them. The resident said he was aware of the pressure ulcers, but related he could not feel them due to the paralysis. He indicated he was unable to determine whether he had a skin impairment. An interview with Employee #33, a registered nurse (RN), on 08/08/14 at 12:00 p.m., revealed she had identified the wound while completing treatments. The RN confirmed no evidence was present to indicate the wound had been identified or treated prior to her assessment. She confirmed the wound was identified on 07/16/14 as a Stage III pressure ulcer, with tunneling and drainage. Additionally, the skin integrity report completed by the RN described the peri wound area as inflamed, and the wound edges macerated (when the skin becomes softened from being wet - it is more susceptible to bacteria and fungi). A physician's orders [REDACTED]. The culture reports revealed the wound grew three (3) different isolates of bacteria. Review of activities of daily living (ADL) records found Resident #68 was totally dependent for toilet use and required the assistance of two (2) staff on 07/15/14 and 07/16/14 on 7-3 shift. The ADL record also indicated he was totally dependent for a bed bath on 07/15/14. Upon further inquiry, Employee #33 confirmed staff should have identified an abnormality while completing resident care. An interview with the interim DON (Employee #44) on 08/08/14 at 12:40 p.m., confirmed the left hip pressure ulcer wound was identified on the date of 07/16/14 as a Stage III ulcer. She related she spoke with therapy after the identification of the pressure ulcer; and it was determined it was caused by the way he laid in the bed. Upon inquiry, as to why the ulcer was assessed as Stage III prior to identification by staff, she indicated the wound was newly acquired, and developed as a Stage III PU with purulent drainage. She denied the skin was broken before that time, and therefore, could not have been identified. An interview with the certified occupational therapy assistant (COTA), Employee #136 on 08/08/14 at 12:30 p.m., revealed he worked with Resident #68 for ADLs and transfers with the slide board, and strengthening exercises. He related he sometimes assisted with the resident's shower, but not routinely. He said he did not complete a body assessment at the time of the shower, to observe for potential issues with skin. He related he concentrated on ADL skills. The COTA indicated he may or may not have been able to observe the lower part of the resident's back/hip area, due to positioning in the chair. He related he was not aware of a pressure ulcer on the resident's left lower back and hip area. He said, I knew he had an area on his coccyx. Therapy notes were reviewed with Employee #136, at which time he verified he had not showered Resident #68 during therapy sessions from 07/11/14 through 07/15/14. The COTA related he had not visualized the posterior aspect of the resident's body during transfers due to the area was covered; and confirmed he could not verify he observed the left lower back and hip area while completing the resident's shower on 07/16/14, due to the shape of the shower chair. Another interview with the interim DON, on 08/08/14 at 1:30 p.m., revealed she believed the Stage III pressure ulcer with tunneling and purulent drainage, which was cultured with three (3) strains of bacteria, happened just prior to finding it, because pressure ulcers can develop in 2 hours, and it may have come from the inside out. She denied the resident had any change in skin tone or impairment prior to identification. Additionally, the vice president of operations, Employee #146, related, It was only the size of a dime. | 2017-08-01 |
| 7154 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 248 | D | 0 | 1 | XYYM11 | Based on observation, family interview, record review, and staff interview, the facility failed to provide an activity program according to a resident's identified interests and needs for one (1) of three (3) sampled residents. The facility did not ensure Resident #107 was consistently invited/reminded to attend group activities. Resident identifier: #107. Census: 111. Findings include: a) Resident #107 Observations, during Stage 1 of the Quality Indicator Survey (QIS), on 09/09/13, and during the morning hours of 09/10/13, found the resident was in his room. He did not come out of his room to attend activities. During an interview with Resident #107's family, on 09/09/13 at 3:07 p.m., a family member voiced a concern the resident had not been reminded/invited to attend group activities. On 09/13/13, review of the resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/27/13, found under Item F0500 E., the resident was assessed as liking to attend group activities. Review of the resident's activity/recreation assessment, on 09/13/13 at 3:15 p.m., found Resident #107 was assessed as liking large group activities. The resident's care plan was reviewed on 09/13/13 at 3:20 p.m. One (1) of the interventions was for the resident to be provided reminders of activities and to be invited to attend activities. Review of the activity attendance sheet, on 09/1313 at 3:30 p.m., revealed the resident had not been consistently invited/reminded to attend group activities. An interview was conducted on 09/11/13 at 10:15 a.m. with Employee #108, the activities director (AD). When asked, Does the staff remind/invite the resident to attend group activities?, she replied, We have no documentation that the resident was consistently invited/reminded and assisted to attend group activities. She further stated, The resident has not attended group activities due to behaviors. When asked, Does the resident have any documented behaviors during activities?, she confirmed there was no evidence Resident #107 had behaviors during an activity within the last month. | 2017-07-01 |
| 7155 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 272 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of thirty-one (31) Stage 2 sample residents. Resident #174's assessment was not coded accurately regarding urinary continence. Resident identifier: #174. Census: 111. Findings include: a) Resident #174 Review of the resident's significant change MDS assessment, with an assessment reference date (ARD) of 07/01/13, on 09/11/13 at 11:00 a.m., found assessment item H0300 was coded to identify the resident as always incontinent Further review of the medical record, on 09/11/13 at 11:20 a.m., found copies of the Resident Functional Performance Record, completed daily by the nursing assistants, which reflected the resident was continent of bladder functioning during the look back period, 06/25/13 through 07/01/13, the time frame for which the MDS was completed. Employee #63, a registered nurse MDS manager, was interviewed on 09/11/13 at 12:55 p.m. Employee #63 compared the information from the Resident Functional Performance Record to the 07/01/13 MDS and stated, It would appear the resident was continent. She stated she did not complete the MDS and she would send Employee #55, who had completed the MDS, to speak with the surveyor. At 1:28 p.m. on 09/11/13, Employee #55, a registered nurse MDS manager, stated she was responsible for completion of the resident's 07/01/13 MDS. Employee #55 verified the look back period for the 07/01/13 MDS was 06/25/13 through 07/01/13. She looked at the Resident Functional Performance Record completed by the nursing assistants and stated, I made a mistake, she was continent of bladder. I will complete a corrected MDS and submit it. She provided a copy of her MDS collective data used to complete the 07/01/13 MDS. She stated, I knew she was continent when I completed the MDS, I just made a mistake. On 09/11/13 at 2:00 p.m., the administrator stated the facility did not have a policy pertaining to the completion of the MDS. She stated the facility just followed the Resident Assessment Instrument (RAI) Manual. The administrator and director of nursing (DON) were made aware of the coding error on 09/13/13 at 2:00 p.m. The DON acknowledged the MDS was coded incorrectly. | 2017-07-01 |
| 7156 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 278 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the individual completing and certifying the accuracy of the minimum data set (MDS) assessment for one (1) of thirty-one (31) sample residents failed to ensure the assessment was coded accurately. Resident #174's assessment did not accurately reflect the resident's urinary continence status. Resident identifiers: #174. Census: 111. Findings include: a) Resident #174 Review of the resident's significant change MDS assessment, with an ARD of 07/01/13, on 09/11/13 at 11:00 a.m., found assessment item H0300 was coded to identify the resident as always incontinent Further review of the medical record, on 09/11/13 at 11:20 a.m., found copies of the Resident Functional Performance Record, completed daily by the nursing assistants, which reflected the resident was continent of bladder functioning during the look back period, 06/25/13 through 07/01/13, the time frame in which the MDS was completed. Employee #63, a registered nurse MDS manager, was interviewed on 09/11/13 at 12:55 p.m. Employee #63 compared the information from the Resident Functional Performance Record to the 07/01/13 MDS and stated, It would appear the resident was continent. She stated she did not complete the MDS and she would send Employee #55, who had completed the MDS, to speak with the surveyor. At 1:28 p.m. on 09/11/13, Employee #55, a registered nurse MDS manager, stated she was responsible for completion of the resident's 07/01/13 MDS. Employee #55 verified the look back period for the 07/01/13 MDS was 06/25/13 through 07/01/13. She looked at the Resident Functional Performance Record completed by the nursing assistants and stated, I made a mistake, she was continent of bladder. I will complete a corrected MDS and submit it. She provided a copy of her MDS collective data used to complete the 07/01/13 MDS. She stated, I knew she was continent when I completed the MDS, I just made a mistake. On 09/11/13 at 2:00 p.m. the administrator stated the facility did not have a policy pertaining to the completion of the MDS. She stated the facility just followed the Resident Assessment Instrument (RAI) Manual. The administrator and director of nursing (DON) were made aware of the coding error on 09/13/13 at 2:00 p.m. The DON acknowledged the MDS was coded incorrectly. | 2017-07-01 |
| 7157 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 280 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) of thirty-one (31) residents reviewed during Stage 2 of the survey. The physician ordered the discontinuation of a resident's anti-anxiety medication. A subsequent revision of the resident's care plan contained focus statements and interventions related to the use of the anti-anxiety medication. Resident Identifier: #88. Facility Census: 111. Findings Include: a) Resident #88 The resident's medical record was reviewed at 2:34 p.m. on 09/10/2013. This review revealed a physician's orders [REDACTED]. The resident's care plan was reviewed. The care plan had revision dates of 09/06/13 and 09/07/13. The post-revision care plan included a focus statement of Potential for decline in mood and cognition related to [DIAGNOSES REDACTED]. An additional focus on the care plan was, Chronic/Progressive decline characterized by: deficit in memory, judgement, decision making and thought process related to dementia/Alzheimer Disease. Receiving anti-anxiety medication for dementia, and anti-depressant (being used for appetite stimulant). The resident's care plan also contained the following intervention related to the resident's ineffective coping skills, Administer medications as ordered for dementia and anxiety. The care plan also indicated the facility should monitor for side effects of the anti-anxiety medication. Employee #1, Director of Nursing (DON), was interviewed at 8:21 a.m. on 09/11/13. She confirmed the resident's anti-anxiety medication was discontinued and the resident was not receiving any other anti-anxiety medication at that time. The DON confirmed Resident #88's care plan contained focus statements and interventions which indicated the resident was still receiving an anti-anxiety medication. She confirmed the revision date of the care plan was after the date the resident's anti-anxiety medication was discontinued and the care plan should have been revised to reflect the change. | 2017-07-01 |
| 7158 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 282 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement a comprehensive care plan for one (1) of thirty-one (31) Stage 2 sample residents. Resident #105's care plan included interventions related to monitoring the resident's [MEDICAL TREATMENT] site. Review of the resident's medical record found no evidence the facility implemented the care plan to assess the resident's [MEDICAL TREATMENT] site as identified in the care plan. Resident identifier: #105. Facility census: 111. Findings include: a) Resident #105 Review of this resident's medical record identified this resident received [MEDICAL TREATMENT] services outside of the facility. Review of the resident's care plan found a plan had been established to observe the Tessio site (the [MEDICAL TREATMENT]) for signs and symptoms of infection. Review of the treatment record for Resident #105 found no evidence the interventions to assess the Tessio site had been implemented. An interview conducted with Employee #1 (director of nursing), on 09/10/13, at 3:30 p.m., confirmed the facility failed to implement the interventions to assess the resident's Tessio site. . | 2017-07-01 |
| 7159 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 309 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of thirty-one (31) Stage 2 sample residents was provided care and services as ordered by the physician. The facility failed to implement the resident's physician's orders [REDACTED]. Resident identifier: #139. Facility census: 111. Findings include: a) Resident #139 During Stage 1 of the quality indicator survey (QIS), Employee #18, the unit manager on south wing (the unit where Resident #139 resided) was interviewed at 1:03 p.m. on 09/09/13. When asked the question from the QIS, Does the resident receive a nutritional supplement, defined as a prescribed high protein high calorie nutritional supplement between or with meals (there must be documentation in the medical record), Employee #18 stated, Yes, then showed the current Medication Administration Record [REDACTED]. Resident #139 was interviewed during Stage 1 of the QIS at 2:11 p.m. on 09/09/13. When asked about the food, the resident stated, I gained 2 or 3 pounds when I got a milkshake, but they don't send it anymore. Haven't had one for 2 or 3 weeks. The resident explained he had lost weight and he felt he needed the milkshake, to gain some more weight. According to the resident, he liked the milkshakes and he needed them. Upon conclusion of the interview with the resident, at 2:30 p.m. on 09/09/13, Employee #3, a nursing assistant, was outside the resident's door passing the 2:00 p.m. snacks. Upon inquiry regarding Resident #139's supplement, Employee #3 stated the resident only had a cookie on the snack cart. She stated, He used to get a milkshake, but he hasn't had one for a while now. Employee #3 then gave the cookie to Resident #139. The director of nursing (DON) appeared during the interview with Employee #3 and stated she would go get a milkshake for the resident. At 3:00 p.m. on 09/09/13, observation revealed the resident had consumed 100% of the milkshake. The dietary manager, Employee #152, was interviewed at 3:01 p.m. on 09/09/13. When asked why the resident did not receive the 2:00 p.m. nutritional supplement ordered by the physician, the dietary manager provided a copy of the supplement/snack list for 09/09/13 and stated, I don't have anything to say he gets a milkshake. He just gets a snack not a house shake. The dietary manager stated the resident had not received a supplement (house shake) since 08/28/13. Review of the resident's medical record, during Stage 2 of the QIS, on 09/11/13, found a current physician's orders [REDACTED]. (ounces) a day, three (3) times a day. The original order was written on 01/17/13. An interview was conducted with the administrator, the DON, and the assistant director of nursing (ADON) at 8:45 a.m. on 9/11/13. The DON said she had researched the situation and had found the dietitian had stopped the house shake on 08/28/13 because the resident had gained weight. The dietitian communicated this to the dietary manager, but did not get a physician's orders [REDACTED]. The DON verified the supplement was ordered on [DATE] because the resident had lost weight. She also verified a physician's orders [REDACTED]. | 2017-07-01 |
| 7160 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 329 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of five (5) a residents who triggered the care area of unnecessary medications during Stage 2 of the quality indicator survey (QIS) was free from unnecessary medications. The resident was receiving [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The facility failed to identify the specific behaviors exhibited by the resident for which the medication was prescribed. Failure to identify the specific behaviors also affected the facility's ability to monitor the actual benefit of the medication. Resident identifier: #30. Facility census: 111. Findings include: a) Resident #30 Medical record review found the resident was receiving the anti-anxiety medication, [MEDICATION NAME] 0.5 milligrams (mg) two (2) times a day for a [DIAGNOSES REDACTED]. Review of the facility's psychopharmacological drug monthly flow records, for 06/06/13 through 09/10/13, found the specific behaviors exhibited by the resident for the use of [MEDICATION NAME] were not described. Each of the monthly flow records listed only anxious as the behavior exhibited by the resident. The director of nursing (DON), on 09/10/13 at 4:04 p.m., was asked how nursing staff were monitoring the resident to determine if the [MEDICATION NAME] was effective. The DON stated she had just provided an in-service on this particular subject two (2) weeks ago. She stated the September 2013 flow record should identify the specific behaviors exhibited by the resident which warranted the use of [MEDICATION NAME]. When the DON provided a copy of the monthly flow record for September, she stated, I can't believe they did this, they know anxious is not a behavior. During the interview, the DON also acknowledged there were no behaviors documented on the behavior monitoring sheets. She also confirmed the behavior monitoring sheets did not describe any specific behaviors for the use of [MEDICATION NAME]. Review of the nurses' notes during the time frame of 06/01/13 through 09/10/13, found no documentation pertaining to any existence or non-existence of resident behaviors. An interview was conducted with the administrator, DON, and assistant director of nursing (ADON), Employee #47, at 8:20 a.m. on 09/11/13. The ADON stated the targeted behaviors for the use of [MEDICATION NAME] were hitting, cursing, and biting. The administrator stated, We will fix the behavior sheets to include the appropriate behaviors. Review of a consultation report by the pharmacist on 08/12/13 found the pharmacist recommended, Please re-evaluate continued use of [MEDICATION NAME] ([MEDICATION NAME]), perhaps consider decreasing to [MEDICATION NAME] 0.5 mg. daily if appropriate. Monitoring during tapering should include: 1) Heart rate 2) gastrointestinal distress and 3) recurrence of symptoms for which the drug was prescribed. The physician responded to the pharmacist recommendation on 09/06/13 with, anxiety currently controlled - hitting and biting at staff improved at this time. The licensed practical nurse (LPN), Employee #106, was observed passing medications on the resident's unit on 09/11/13 at 9:16 a.m. She was asked what behaviors the resident exhibited to warrant the use of [MEDICATION NAME]. The LPN stated the resident refused medications at times and was fidgety. She stated, Just the other day, she wanted me to look in her purse; she said there was a church inside her purse. Review of the medical record found the resident had hallucinations for which she received [MEDICATION NAME]. | 2017-07-01 |
| 7161 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 505 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the facility failed to ensure the physician was notified of all laboratory results in a timely manner for one (1) of five (5) Stage 2 sample residents reviewed for laboratory results. Resident identifier: #21. Facility census: 111. Findings include: a) Resident # 21 Review of medical records, on 09/11/13 at 1:00 p.m., found laboratory tests (Basic Metabolic Panel (BMP) and Complete Blood Count (CBC)) had been ordered and obtained for Resident #21 on 09/09/13. The attending physician was called the results of the CBC on 09/09/13. No verification could be located to indicate the results of the BMP had been called to the physician. An interview with Employee #1, the director of nursing (DON), on 09/11/13 at 3:10 p.m., confirmed the attending physician was not notified of the results of the BMP. The DON said both of the tests were ordered STAT (immediately). The facility received the results of the CBC, but not the BMP. The DON said it was the facility's responsibility to call the lab if results were not provided. She confirmed the facility failed to ensure the receipt of the BMP results and notify the physician. | 2017-07-01 |
| 7162 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 514 | E | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medical records were complete, accurately documented, readily accessible, and/or systematically organized for five (5) of thirty-one (31) Stage 2 sample residents, and one (1) resident identified through a random opportunity for observation. Resident #67's physician's order did not contain the amount of eye drops to be administered. Resident #139 was not receiving a house supplement as ordered; however, staff documented the consumption of a snack on the record as the house supplement consumption. Resident #37's admission nursing assessment and skin integrity reports had conflicting measurements and location of pressure ulcers documented. Resident #184's hospice order was not placed on the monthly orders. Nursing staff continued to document on the medication record after a medication was discontinued for Resident #88. Medication administration records for Resident #150 were found in Resident #88's medical records. Resident identifiers: #67, #37, #139, #184, #88, and #150. Facility census: 111. Findings include: a) Resident #67 Review of medical records, on 09/12/13 at 9:00 a.m., revealed a physician's order for [MEDICATION NAME] 0.5% eye drops solution, twice a day; left eye. An interview was conducted with Employee #45, licensed practical nurse, (LPN) on 09/12/13 at 9:26 a.m. When asked how she determined how many eye drops to instill in the left eye, she said, The order should contain how many drops to instill. At that time, she confirmed the resident's order did not contain how many eye drops to instill in the left eye. b) Resident #37 Review of the resident's medical records, on 09/11/13 at 10:00 a.m., revealed the admission nursing assessment and skin integrity reports had conflicting measurements and locations regarding the resident's pressure ulcers. The admission nursing assessment indicated the resident had a pressure ulcer on the left hip and coccyx. Both were identified as Stage II pressure ulcers. According to the skin integrity sheets and the minimum data set (MDS) assessment, the resident had deep tissue injury (DTI) on the right hip and coccyx. These reports noted both pressure areas were present on admission. An interview with Employee #1, the director of nursing (DON), was conducted on 09/11/13 at 11:30 a.m. She confirmed the admission nursing assessment was inaccurate related to the measurements and location of the pressure ulcers. The DON further confirmed the measurements and location of the pressure ulcers were accurate on the skin integrity reports. c) Resident #139 During Stage 1 of the quality indicator survey (QIS), Employee #18, the unit manager on south wing, (the unit where Resident #139 resided) was interviewed at 1:03 p.m. on 09/09/13. When asked the question from the QIS, Does the resident receive a nutritional supplement, defined as a prescribed high protein high calorie nutritional supplement between or with meals (there must be documentation in the medical record), Employee #18 stated, Yes, then showed the current medication administration record (MAR) for September 2013. The MAR indicated the resident was consuming a 4 ounce house shake at 10:00 a.m., 2:00 p.m., and 8:00 p.m. daily. Resident #139 was interviewed during Stage 1 of the QIS at 2:11 p.m. on 09/09/13. When asked about the food, the resident stated, I gained 2 or 3 pounds when I got a milkshake, but they don't send it anymore. Haven't had one for 2 or 3 weeks. Upon conclusion of the interview with the resident, at 2:30 p.m. on 09/09/13, Employee #3, a nursing assistant, was outside the resident's door passing the 2:00 p.m. snacks. Upon inquiry regarding Resident #139's supplement,. Employee #3 stated the resident only had a cookie on the snack cart. She stated, He used to get a milkshake, but he hasn't had one for a while now. Employee #3 then gave the cookie to Resident #139. The dietary manager, Employee #152, was interviewed at 3:01 p.m. on 09/09/13. When asked why the resident did not receive the 2:00 p.m. nutritional supplement ordered by the physician, the dietary manager provided a copy of the supplement/snack list for 09/09/13 and stated, I don't have anything to say he gets a milkshake. He just gets a snack not a house shake. The dietary manager stated the resident had not received a supplement (house shake) since 08/28/13. Review of the resident's medical record, during Stage 2 of the QIS, on 09/11/13, found a current physician's order for a supplement. It was for a house shake 4 oz. (ounces) a day, three (3) times a day. The original order was written on 01/17/13. An interview was conducted with the administrator, the DON, and the assistant director of nursing (ADON) at 8:45 a.m. on 9/11/13. These employees were asked to explain why nursing staff documented a percentage of consumption for the supplement (house shake) on the MAR when the resident had not received it since 08/28/13. The DON and ADON stated staff were documenting the percentage of the snack the resident consumed. The unit manager, Employee #152, was interviewed at 10:00 a.m. on 09/11/13. She was asked to explain why nursing staff documented the percentage of consumption of a supplement when the resident had not received the supplement (house shake) shake since 08/28/13. She stated she was documenting the percentage of whatever snack was provided to the resident. d) Resident #184 Information provided upon entrance revealed this resident was receiving hospice services. Review of the medical record revealed no order for hospice services. During an interview with the director of nursing, Employee #1, on 09/11/13 at 2:00 p.m., she confirmed there were no current physician orders for hospice services. Employee #1 said there were no orders, since the beginning ones, which stated the physician would accept hospice orders. On 09/11/13 at 4:10 p.m., a medical record staff member, Employee #98, said she could not find a current order for hospice. Employee #98 said the order was written and discontinued each time the resident was hospitalized . Upon the last return from hospitalization , an order was not written for hospice services, even though the resident currently received hospice services. e) Resident #88 The resident's medical record was reviewed at 2:34 p.m. on 09/10/2013. This review revealed a physician's order, dated 08/29/13, which indicated the resident's [MEDICATION NAME] was to be discontinued on 08/29/13. On 08/20/13, the medication administration record (MAR) was reviewed. The resident's [MEDICATION NAME] was documented on the MAR. Review of the MAR for the dates of 08/30/13 and 08/31/13 revealed the licensed practical nurse (LPN) initialed she gave the medication on 08/30/13 and 08/31/13. An interview with the DON, at 8:21 a.m. on 09/11/13, revealed when a medication was discontinued, the medication was taken from the medication cart and sent back to the pharmacy. She reported she was not sure why the nurse initialed the MAR for 08/30/13 and 08/31/13. The DON reported the nurse's initials should not have been on the MAR indicating she had given the medication. Employee #106, LPN, was interviewed on 09/11/13, at 9:00 a.m. She stated she did not know why she initialed the MAR on 08/30/13 and 08/31/13. The LPN stated she was the LPN who took the order discontinuing the [MEDICATION NAME]. She reported when it was discontinued, she pulled the medication out of the medication cart and sent it back to the pharmacy. The LPN stated she did not give the resident the medication, and should not have initialed the MAR indicating she had given the medication. f) Resident #150 During a medical record review, at 8:30 a.m. on 09/12/13, the June 2013 and August 2013 medication administration records (MARs) for Resident #150 were found in the medical record of Resident #88. Interview with Employee #98, medical records director, at 9:06 a.m. on 09/12/13, confirmed Resident #150's MAR for the months of June 2013 and August 2013 were misfiled in the medical record of Resident #88. Employee #98 stated there was a mistake made, and this information was filed in the wrong medical record. | 2017-07-01 |
| 7340 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 164 | D | 1 | 0 | MSKF11 | Based on observation, review of facility policy and procedure, and staff interview, the facility failed to provide personal privacy for a resident during an observation of a pressure ulcer on the resident's coccyx. When observing Resident #59 ' s pressure ulcer, the nursing staff did not close the blinds to the window in the resident ' s room or pull the privacy curtains completely around the resident's bed. This was true for one (1) of five (5) residents whose pressure ulcers were observed. Resident identifier: #59. Facility census: 117. Findings include: a) Resident #59 On 05/29/14 at 11:10 a.m., during an observation of Resident #59's Stage II pressure ulcer located on the coccyx, Employee #43, a registered nurse (RN), did not close the blinds to an outside window. A parking lot was located outside the window where random observations revealed people walked down the sidewalk to their cars. In addition, the privacy curtain was pulled the length of Resident #59's bed, but was not pulled around the foot of the bed. Two (2) visitors and a roommate were also in the room during the observation. A review of the facility ' s policy and procedure titled Wound Dressings: Aseptic, on 05/29/14 at 1:45 p.m., revealed Section 7. included, Explain the procedure and provide privacy. The nursing home administrator (NHA) and the director of nursing (DON) were present during this policy and procedure review. When asked whether she agreed there was a problem with providing privacy during the observation of Resident #59's pressure ulcer, the NHA smiled and shrugged her shoulders. | 2017-05-01 |
| 7341 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 280 | D | 1 | 0 | MSKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the care plan for a resident was revised to reflect the nothing by mouth (NPO) status when the resident was receiving nourishment by tube feeding. This was true for one (1) of three (3) sample residents reviewed with tube feedings. Resident identifier: #5. Facility census: 117. Findings include: a) Resident #5 On 05/28/14 at 2:26 p.m., a review of Resident #5 ' s care plan revealed an intervention, dated 05/20/14, of Encourage increased fluid intake. An intervention, dated 05/21/14, was to Offer fluids frequently, encourage to drink all fluids offered on trays. Water pitcher in reach at bedside. A review of the current physician's orders [REDACTED]. On 05/28/14 at 3:30 p.m., an interview with the nursing home administrator (NHA) revealed she had been made aware of this care plan issue by her staff and had implemented an audit of all resident care plans who were receiving tube feedings to ensure there were no other issues with the care plans. | 2017-05-01 |
| 7342 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 441 | E | 1 | 0 | MSKF11 | Based on observation, facility policy and procedure review, review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) handwashing procedure, review of the Centers for Disease Control handwashing recommendations, and staff interview, the facility failed to ensure staff employed proper handwashing techniques, and practiced aseptic dressing procedure to prevent cross contamination and the spread of infection. Nursing staff members (Employees #43 and 82) were observed using paper towels to turn off the water faucet, then dry their hands with the contaminated paper towels for. During a pressure ulcer dressing change on Resident #23, the nurse placed a bag directly on the resident ' s bed and returned the bag to the treatment cart used for all residents, thereby potentially cross contaminating all dressing bags in the treatment cart. A nurse placed a clean dressing and a hydrogel container on Resident #23 ' s over-bed table without benefit of a barrier to prevent contamination of the dressing materials. These practices had the potential to affect more than a limited number of residents. Resident identifiers: Resident #6, #5, #59, and #23. Facility census: 117. Findings include: a) Resident #6 On 05/29/14 at 11:00 a.m., Employee #82, a nurse, was observed washing her hands, turning off the water faucet with paper towels and then drying her hands with the contaminated paper towels after providing care to the resident. b) Resident #5 On 05/29/14 at 11:06 a.m., Employee #82, a nurse, was observed washing her hands, turning off the water faucet with paper towels and then drying her hands with the contaminated paper towels after providing care to the resident. c) Resident #59 On 05/29/14 at 11:10 a.m., two (2) nurses (Employee #82 and #43) were observed washing their hands, turning off the water faucet with paper towels, and then drying their hands with the contaminated paper towels after providing care to this resident. When brought to the attention of Employee #82, she agreed she had not followed the proper handwashing procedure. d) Resident #23 On 05/29/14 at 11:22 a.m., a nurse (Employee #82) was observed completing a pressure ulcer dressing for Resident #23. Employee #82 brought a plastic bag containing dressing supplies into the resident ' s room, placed the bag on the resident ' s bed, and returned the bag to the treatment cart used for all residents. The clean dressing and hydrogel container were placed on Resident #23's over-bed table without a barrier being in placed on the over-bed table to prevent contamination of the dressing materials. e) A review of the facility ' s policy and procedure titled Wound Dressings: Wound found it included, - 4. Clean over-bed table - 5. Place clean barrier on the over-bed table and place supplies on the barrier. f) CMS ' s State Operations Manual, includes, Recommended techniques for washing hands with soap and water include wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 15 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a disposable towel; and turning off the faucet on the hand sink with the disposable paper towel. This is consistent with the recommendations from the Centers for Disease Control. g) On 05/29/14 at 1:45 p.m., the administrator and the director of nursing were present during the policy and procedure review. When the NHA was asked if she agreed with the failure to perform the appropriate handwashing procedure and pressure ulcer dressing procedure, the NHA smiled and shrugged her shoulders. | 2017-05-01 |
| 8181 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 279 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan reflective of an accurate assessment of the resident. The resident had a deep tissue injury (DTI) to his buttocks. According to the care plan, a contributing factor related to the development of the DTI was incontinence; however, the resident had a suprapubic catheter and a [MEDICAL CONDITION]. This was true for one (1) of four (4) residents whose care plan was reviewed during the complaint investigation. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Medical record review, on 07/30/13, found a care plan for the DTI, initiated on 07/29/13. The care plan addressed a problem of DTI to left buttocks surrounded by incontinence associated [MEDICAL CONDITION] (IAD) related to immobility and incontinence. Further review of the medical record found the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. At 5:00 p.m. on 07/30/13, the director of nursing verified the care plan was not correct. She stated incontinence was not a contributing factor in the development of the DTI as the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. | 2016-07-01 |
| 8182 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 282 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written care plan for Resident #116 related to the maintenance of a Foley catheter. This was true for one (1) of seven (7) residents whose care plans were reviewed during the complaint survey. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Resident #116 was noted to have an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of care plan, on 07/30/13 at 11:00 a.m., found an intervention for the nursing staff to Empty catheter drainage bag every shift and record. Review of medical records, on 07/30/13 at 12:00 p.m., found the staff did not consistently record the amount emptied from the catheter bag as directed by the written care plan. In interviews with Employee #56, a licensed practical nurse (LPN), and Employee #47, a registered nurse (RN), on 07/30/13 at 12:30 p.m., both confirmed the catheter bags were emptied every shift and the urine outputs were not recorded routinely. Occasionally the licensed nurse did record the output in the nurses' notes. In an interview conducted on 07/30/13 at 1:30 p.m., Employee #1, the director of nursing, (DON) confirmed the staff did empty catheter bags every shift, but did not record the resident's output every shift as directed in the resident's written care plan. | 2016-07-01 |
| 8183 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 309 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident who had an indwelling Foley catheter. This practice affected one (1) of five (5) residents reviewed during the complaint survey who had an indwelling Foley catheter. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Review of medical records, on 08/01/13 at 11:30 a.m., noted this resident had been admitted to the facility on [DATE]. The resident had an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of nurses' notes found a note written by Employee #66, a licensed practical nurse (LPN), on 07/15/13 at 2:45 p.m. The nurse noted (typed as written), Foley cath changed due to leaking. 24 french 30 cc balloon placed without difficulty. Redness to right and left groin area noted, treatment ordered. The next nurse's note concerning the Foley catheter was written on 07/20/13 at 12:00 p.m. The nurse noted Foley cath to BSD (bedside drainage) intact, no leaking, sediment urine noted. The next nurse's note concerning the Foley was dated 07/25/13 at 10:30 p.m. The nurse documented Foley patent to BSD (bedside drainage) with approx. 300 cc of urine, dark yellow. During an interview with Employee #1, the director of nursing (DON), on 08/01/13 at 1:00 p.m., it was confirmed from review of nurses' notes, the licensed staff had not consistently assessed, monitored, and evaluated the Foley catheter and the nature and amount of the resident's urinary output. | 2016-07-01 |
| 8184 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 441 | D | 1 | 0 | HEN111 | Based on observation, medical record review, and staff interview, the facility failed to maintain proper care of a resident's catheter to prevent the spread of infection. Observation found the resident's catheter drainage bag was lying on the floor. This was true for one (1) of four (4) observations of residents with catheters. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 During the initial tour of the facility, on 07/30/13, the resident was in bed at 9:45 a.m. on 07/30/13. His catheter drainage bag was lying on the floor beside the bed. Employee #46, the assistant director of nursing (ADON) was in the hallway outside the resident's room at 9:45 a.m. on 07/30/13. She was asked to witness the observation. She entered the room and stated, I will get a new bag and change it because of infection control issues. She verified the catheter bag should not be lying on the floor. At 5:00 p.m. on 07/30/13, the director of nursing (DON) was made aware of the above situation. She stated the resident could have knocked the catheter onto the floor by moving around in bed. Further review of the resident's care plan found a problem, initiated on 07/29/13, related to the resident's deep tissue injury, which stated the resident was immobile. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/27/13, found Item G0110, (activities of daily living assistance - bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture,) reflected the resident required the extensive assistance of two (2) staff persons to complete the activity of moving while in bed. . | 2016-07-01 |
| 8185 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 514 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to ensure a permanent entry in the resident's medical record was not changed after being recorded. This was true for one (1) of seven (7) medical records reviewed during the complaint survey. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Review of the resident's current care plan, located on the medical record, on 07/30/13 at 10:15 a.m. found a handwritten entry to the care plan, Deep tissue injury (DTI) to left buttocks surrounded by IAD (incontinence related [MEDICAL CONDITION]) related to immobility and incontinence, this entry was dated 07/29/13. On 07/30/13 at 10:30 a.m. the unit manager, Employee #47, was asked to make a copy of the resident's care plan. When she returned with the care plan, the original problem was no longer on the care plan. A new care plan problem had been written and dated 07/29/13, Deep tissue injury to left buttocks surrounded by MASD (moisture associated [MEDICAL CONDITION]) related to immobility. The surveyor found Employee #47 and Employee #34, a registered nurse, at the nurses station at 10:35 a.m. on 07/30/13. The surveyor spoke to both employees and asked who had changed the original care plan. Employee #34 stated she had re-written the care plan because it was incorrect. Employee #34 stated she saw the resident's DTI could not be due to incontinence because the resident had a catheter and a [MEDICAL CONDITION]. During the discussion with Employees #47 and #34, the director of nursing (DON) came to the nurses' station. The DON told Employee #34 she should have, yellowed out the problem and corrected it on the original copy. Employee #34 was asked for the original copy of the care plan and she said she could not find it. The DON found the original copy of the care plan in the trash can, torn into pieces. The DON stated she would tape the care plan together and give it to the surveyor. On 08/01/13 at 2:45 p.m. the DON provided a copy of the facility's policy for Clinical Records, Charting and Documentation. The policy directed staff to, . Draw a line through an error, write the correction above it, and date and initial the change. Never remove, use correction fluid or erase documentation. The DON confirmed the original care plan had been removed from the resident's chart on 08/01/13 at 2:45 p.m. , | 2016-07-01 |
| 8633 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-28 | 371 | E | 0 | 1 | 8VU011 | Based on observation, staff interview, and the facility's Dented Can Policy, the facility failed to ensure proper food storage to prevent possible foodborne illness. This had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) On 03/26/13 at 8:50 a.m., during an observation of the kitchen food pantry, a dented #10 can of beef stew was discovered on the shelf. The facility failed to dispose of the dented can of beef stew to eliminate a possible food safety risk. An interview was conducted on 03/26/13 at 8:51 a.m. with Employee #154, the Regional Dietary Manager. She stated the dented #10 can of beef stew should have been pulled from the rack and agreed there was a possibility the dent was severe enough to represent a health issue. On 03/26/13 at 9:17 a.m., Employee #154, the Regional Dietary Manager presented the facility's Dented Can Policy. This policy indicated cans with serious defects or severe dents could compromise the integrity of the can, allowing the contents unsafe for consumption. However, the policy did not provide instructions about what was to be done with a dented can. | 2016-04-01 |
| 8752 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 152 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for residents who had been determined to lack the capacity to make informed medical decisions, a legal surrogate was designated in accordance with State law to exercise the resident's rights to the extent provided by the law. This was found for two (2) of four (4) residents whose records were reviewed. Resident identifiers: #116 and #117. Facility census: 115. Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 3/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. He was seventy (70) years old. His [DIAGNOSES REDACTED]. He was determined by a physician to lack the capacity to make informed healthcare decisions on 02/27/13. He was admitted to the facility for skilled therapy services designed to strengthen him, and improve his ability to assist with activities of daily living (ADLs) to allow him to return home with his son and daughter-in-law. There was an indication in the admission paperwork that a health care surrogate (HCS) had been appointed. Further review found a form entitled West Virginia Health Care Surrogate Designation, which had been faxed to the facility on [DATE] from the admitting hospital. The form indicated the resident's sister had consented over the telephone to act as the resident's HCS on 02/18/13. The cause of Resident #116's incapacity to make his own decisions was not completed. The expected duration of his incapacity to make his own decisions was not completed. The person that the physician intended to appoint as HCS was not named. There was a signature in the space marked attending physician, but the signature was not dated. During an interview, on 03/13/13 at 8:45 a.m., the administrator, Employee #38, stated that a new health care surrogate appointment form containing all the information required by the West Virginia Health Care Decisions Act ?16-30-1 should have been completed by the facility following the facility's determination upon admission that Resident #116 continued to lack the capacity to make informed health care decisions. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. Resident #117 was a fifty-nine (59) resident who was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. During the review of the medical record, questions arose regarding Resident #117's capacity to make informed medical decisions and also regarding sufficient appropriate provisions to ensure that an authorized decision maker was in place. Resident #117 signed his physician's orders [REDACTED]. He indicated his wishes for emergency medical interventions and end of life care on 03/07/12. He then signed all admission paperwork, including an authorization to provide medical treatment on 03/08/12. The attending physician determined the resident was incapable of making informed medical decisions on 03/08/12. There was no medical power of attorney (MPOA), health care surrogate (HCS) appointment, or any other evidence that a legal and appropriate decision maker was in place. Social services notes, dated 03/14/12, stated (typed as written): Resident was deemed incapable of making self-decisions by physicians but no reason given. Physician consulted to reevaluate. Resident has no MPOA or HCS on chart. A social services note dated three (3) months later, on 06/13/12, stated (typed as written): HCS completed and waiting for physician signature. No HCS was found in the medical record. After discussion regarding this issue on 03/12/13 at 3:47 p.m., the administrator presented a health care surrogate appointment form that had been completed on 02/03/12, while the resident was in the hospital. She said, and the FAX transmission date confirmed, that this form had never actually been in the record or available to staff, as it was just faxed to the facility on [DATE]. What was found in the medical record was a determination made at the hospital 26 days later on 02/29/12. This document indicated Resident #117 did possess the capacity to make informed medical decisions, which would have negated the health care surrogate's authority. The social worker for Resident #117, Employee #37, was interviewed on 03/12/13 at 2:40 p.m. He was asked about the HCS status of Resident #117 following his admission. He said he could not speak to that as he only began his employment at the facility in September 2012. He said he thought there was a surrogate form on the chart, but was not sure. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She confirmed that she was not able to provide any additional documentation regarding the completion of a health care surrogacy form following the determination that Resident #117 lacked the capacity to make informed medical decisions on 03/08/12. | 2016-03-01 |
| 8753 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 203 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed, before a discharge, to notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge in writing and in a language and manner they understood, the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement the resident had the right to appeal the action to the State; and the name, address and telephone number of the State long term care ombudsman. This was found for two (2) of four (4) residents whose records were reviewed. Facility census: 115 Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 03/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. Resident #116 was discharged back to his son's home on 3/10/13. Discharge planning was appropriate, but there was no evidence the health care surrogate (HCS) received any written notice of discharge and applicable appeal rights. This information was specifically requested from administrator on 03/13/13 at 8:45 a.m., but could not be located by the time of exit. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 03/12/13 at 8:59 a.m. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. He was subsequently discharged to an adult care home on 11/08/12. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She was not able to provide any supporting documentation to show that Resident #117's sister, who the facility considered the legally appointed health care surrogate (HCS), was notified in writing of his discharge and thereby given her appeal rights and contact information. | 2016-03-01 |
| 8754 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 204 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, interview of the owner of a receiving facility, and family interview, the facility failed to provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility to a legally unlicensed adult care home. This was found for one (1) of four (4) records reviewed. Facility census: 115. Findings include: a) Resident #117 The medical record of Resident #117, was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. This fifty-nine (59) year old man, was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. Upon admission to the nursing home, his comprehensive assessment (MDS) of 03/13/12, under section G0110, G0120, and G0300 documented his ability as: Bed Mobility coded: 0,0 indicating 'independent with no help from staff Transfer ability coded: 2,2 indicating 'limited assistance of one staff Walking in room coded: 3,3 indicating 'extensive assistance of two or more staff Walk in corridor coded: 8,8 indicating 'did not occur Locomotion on unit coded: 3,2 indicating 'extensive assistance of one staff Locomotion off unit coded: 3,2 indicating 'extensive assistance of one staff Dressing coded: 3,2 indicating 'extensive assistance of one staff Eating coded: 0,1 indicating 'independent with set up help only Toileting coded: indicating 'limited assistance of one staff Personal Hygiene coded: 0,1 indicating 'set up help only Bathing coded: 3,2 indicating 'extensive assistance of one staff Balance sitting to standing coded: 2 indicating 'not steady, only able to stabilize with staff assistance Balance Walking coded: 2 indicating 'not steady, only able to stabilize with staff assistance Turning around coded: 8 indicating 'activity did not occur Moving on/off toilet coded: 2 indicating 'not steady, only able to stabilize with staff assistance Surface to surface transfer coded: 2 indicating 'not steady, only able to stabilize with staff assistance He was placed on therapy services for strengthening and improvement in his independence with activities of daily living (ADL's). His therapy services were stopped on 04/19/12 because he had met all his goals. He did not resume therapy during his stay. His preadmission screening and eligibility determination form (PAS) was approved for payment by Medicaid for three (3) months, with the physician estimating a stay of approximately twenty-one (21) days. The facility subsequently had to submit a PAS to resume payment on 04/26/12. This application was approved for a recommended period of three (3) to six (6) months on 05/07/12. He improved with therapy, and by 06/11/12, his comprehensive assessment (MDS), under section G0110, G0120, and G0300 documented his ability as: Bed Mobility coded: 0,0 indicating 'independent with no help from staff Transfer ability coded: 0,0 indicating 'independent with no help from staff Walking in room coded: as 'not assessed Walk in corridor coded: 8,8 indicating 'activity did not occur Locomotion on unit coded: 0,0 indicating 'independent with no help from staff Locomotion off unit coded: 0,0 indicating 'independent with no help from staff Dressing coded: 0,0 indicating 'independent with no help from staff Eating coded: 0,0 indicating 'independent with no help from staff Toileting coded: 0,0 indicating 'independent with no help from staff Personal Hygiene coded: 0,0 indicating 'independent with no help from staff Bathing coded: 0,0 indicating 'independent with no help from staff Balance sitting to standing coded: 0 indicating 'steady at all times Balance Walking coded: 0 indicating 'steady at all times Turning around coded: 0 indicating 'steady at all times Moving on/off toilet coded: 0 indicating 'steady at all times Surface to surface transfer coded: 0 indicating 'steady at all times The facility again allowed the PAS approval to expire, and this necessitated another submission for approval for Medicaid coverage for long term care level services. With the improvements in his functional abilities, the reviewer denied the application stating he did not require long term care services on 08/20/12. He had to undergo surgery for [REDACTED]. His MDS of 09/10/12 assessed his functional ability as: Bed Mobility coded: 3,2 indicating 'extensive assistance of one staff Transfer ability coded: 3,2 indicating 'extensive assistance of one staff Walking in room coded: 3,2 indicating 'extensive assistance of one staff Walk in corridor coded: 3,2 indicating 'extensive assistance of one staff Locomotion on unit coded: 0,0 indicating 'independent with no help from staff Locomotion off unit coded: 0,0 indicating 'independent with no help from staff Dressing coded: 3,2 indicating 'extensive assistance of one staff Eating coded: 0,1 indicating 'independent with set up help only Toileting coded: 2,3 indicating 'limited assistance of two or more staff Personal Hygiene coded: 3,2 indicating 'extensive assistance of one staff Bathing coded: 3,2 indicating 'extensive assistance of two or more staff Balance sitting to standing coded: 2 indicating 'not steady, only able to stabilize with staff assistance Balance Walking coded: 2 indicating 'not steady, only able to stabilize with staff assistance Turning around coded: 2 indicating 'not steady, only able to stabilize with staff assistance Moving on/off toilet coded: 2 indicating 'not steady, only able to stabilize with staff assistance Surface to surface transfer coded: 2 indicating 'not steady, only able to stabilize with staff assistance An interview was conducted with the comprehensive assessment (MDS) coordinator, registered nurse (RN), Employee #54 on 03/12/13 at 10:00 a.m. She was asked why a significant change of status comprehensive assessment (MDS) was not considered for Resident #117 upon his return from hernia repair surgery. She agreed that his functional ability had declined markedly following the procedure, but said that the interdisciplinary team was in agreement that they anticipated a fairly rapid return to his baseline, and decided to wait for a time to see what happened. She said that he did improve rapidly, and within a couple of weeks, he had returned to near his functional level as assessed on 06/11/12. The facility once again submitted another PAS form for a change in condition, to attempt to get Medicaid payments resumed. This form was submitted on 10/01/12, following his improvement following surgery in September, and was again denied on 10/02/12. The facility was still receiving no reimbursement for Resident #117's stay. There was documentation that numerous attempts were being made to find a location that would accept Resident #117 to allow the facility to discharge him. Social services notes documented that beginning on 09/11/12, assisted living facilities were contacted. The note stated that all were private pay, which Resident #117 could not afford on his approximately $432.00 per month disability benefits. The note said that legally unlicensed adult care homes would be contacted. The record showed that from 09/17/12 until 09/28/12, attempts were made to arrange placement at twenty-seven (27) legally unlicensed adult care homes all over the region. They all had concerns over the care required, they did not accept smokers, or only accepted private pay residents. The record indicated that on 09/28/12, the unlicensed care home to which Resident #117 was ultimately discharged , called to let the social worker know that she would accept him, but needed time to prepare his room. Earlier efforts to obtain placement in another state where Resident #117's sister lived were unsuccessful as the facility there also refused to accept him. The record documents that she was contacted on 09/28/12 and notified of Resident #117's upcoming placement. Transportation problems with two (2) different ambulance services, complications from hernia surgery, and an unspecified emergency at the unlicensed care home delayed the discharge until 11/08/12, when the record shows he was taken to the unlicensed home in the facility van, with a wheelchair and a cane. The social worker for Resident #117, Employee #37, was interviewed on 03/12/13 at 2:40 p.m. He confirmed that Resident #117 had improved following his hernia surgery and within a couple of weeks was back walking with his cane, although he always used his wheelchair to go any appreciable distance. He said that when the preadmission screening was denied, the facility stopped getting paid, and he began to pursue locations for discharge. He said it was very difficult due to Resident #117 having [MEDICAL CONDITION] C, being a smoker, exhibiting inappropriate and aggressive behaviors at times, and not being covered by Medicaid. He said that finally an unlicensed adult care home agreed to take Resident #117 on 09/28/12. Following several logistical problems with the provider and the ambulance services, the facility activities director and a nursing assistant drove Resident #117 to the unlicensed care home in the facility van. He was asked if he had visited the home prior to the discharge to see if it was a safe appropriate location for the discharge. He replied that he had not. He said he spoke with the owner on the phone. He said that she had told him there were seven (7) or eight (8) steps that Resident #117 would have to negotiate. He was asked if he made any effort to determine if Resident #117 could safely negotiate steps. He said he asked the resident, who told him it would be no problem. He was asked if physical therapy was consulted for an assessment of the resident's ability to climb stairs. He stated he thought he had asked them about it, but no formal assessment was requested or completed. None of the goals met when resident #117 was discharged from therapy on 04/19/12 addressed stairs. There was a goal that stated he should be able to negotiate ramps, grass, and gravel. There was no documentation in the record regarding any stairs or any attempts to determine if the location was appropriate for discharge. He was asked if the staff that transported the resident to the home had gone inside to make any assessment of the suitability. He replied that he did not know. He offered that the regional ombudsman had visited the facility later following the discharge and had told him that there were eighteen (18) steps to Resident #117's room, and that he was in a bad situation. The activities director, Employee #87, was interviewed on 03/12/13 at 3:34 p.m. She confirmed that she and a nursing assistant had transported Resident #117 to the unlicensed care home on 11/08/12 in the facility van. She said that they had a TV, three (3) boxes of clothing and personal items, a cane, and a wheelchair. She said she had a bag with his medications. She took it to the front room. The owner was not there, but her son signed for the medications. She said that Resident #117 walked around the front yard, and talked with another resident. She said they left his belongings there, the resident hugged her, and we dropped him off and left. The owner of the legally unlicensed home was interviewed on the telephone on 03/11/13 at 3:23 p.m. She was asked if Resident #117 was still living in her home. S he replied that he was still there. She asked if there was someone who could get him placed somewhere else. She said that he needed to stay over there (the facility). She said he can't get around here, he is not doing good. She said they are trying to find someplace for him to go. He wants to go back to the facility or somewhere closer to his sister (out of state). She said they were having trouble with his medications and that he needed nursing home care. She was asked if she had spoken with the facility about this. She said that she had talked with that man (Employee #37). She stated she told him that Resident #117 needed to stay over there. The health care surrogate was interviewed by telephone on 03/12/13 at 1:59 p.m. She related that she had no problems with the facility, that they treated him very well there. She said that he was in a wheelchair, that it was still sitting on the front porch. She said there were fifteen (15) steps up to his room and he could not get up or down by himself. He just sat up there and smoked. She said the ombudsman was working with him on finding a new place. She stated that the facility did not assess the place, they did not check it to see if it was safe, they just took him there in the van and dropped him off. The administrator was interviewed on 03/12/13 at 3:47 p.m. She confirmed there was no documented effort to ensure a safe and orderly discharge for Resident #117. | 2016-03-01 |
| 9763 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 329 | D | 1 | 0 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents who received antianxiety and/or hypnotic medications received the smallest effective dose for the shortest period of time. A resident received anti-anxiety medication for nearly a year, at a dose higher than that recommended for the elderly. Another resident received a hypnotic medication for sleep for a prolonged period of time. The medication used was one which was typically used only for short-term management of [MEDICAL CONDITION]. Additionally, there was no evidence of non-pharmacological interventions to alleviate the symptoms for either resident. Resident identifiers: #145 and #93. Facility census: 109. a) Resident #145 Review of the medical record revealed this [AGE] year old resident with dementia was admitted to the facility on [DATE]. She was ordered [MEDICATION NAME] (an anti-anxiety medication) one (1) milligram (mg.) twice daily for anxiety on 09/21/11. Approximately two (2) weeks later, the dosage was increased to one (1) mg. three (3) times daily, where it has since remained. Review of manufacturer's recommendations, found that the total daily dose threshold for anxiolytic medication, [MEDICATION NAME], is up to two (2) mg. daily in divided doses for geriatric patients. On 07/03/12 a gradual dose reduction (GDR) was recommended by the consultant pharmacist. The pharmacist recommended a reduction in the [MEDICATION NAME] dosage to 0.5 mg. three (3) times daily. The physician declined to decrease the dose, and gave no rationale for this decision on the pharmacy consultation report form. Review of a physician's progress note, dated 07/03/12, found the physician's assessment of tremor, nervous, and the plan to continue the [MEDICATION NAME] and observe. Review of the behavior monthly flow sheets for June, July, and August 2012, revealed [MEDICATION NAME] was used for the [DIAGNOSES REDACTED]. Further review revealed this form was only sporadically used in June and July, with recordings of only 39 out of a possible 93 shifts. The recorded information indicated the resident experienced few episodes of anxiety, and only on the night shift. Review of the August behavior monthly flow sheet also noted only rare episodes of anxiety. The number of non-pharmacological interventions employed was zero (0) for these three (3) months. Review of the behavior/intervention monthly flow record for September 2012 revealed the targeted behavior [MEDICATION NAME] was treating was that of being afraid. The number of behavioral episodes was zero (0) for each of the shifts through 09/26/12. The number of interventions employed was zero (0) for the same time period. Review of the recapitulation of active physician's orders [REDACTED]. The order date and start date of this medication, was 10/04/11. During an interview with the Director of Nursing, on 09/19/12, at approximately 4:00 p.m., she said she thought there had been two (2) attempts at reducing the [MEDICATION NAME] dose in the past year. No information was produced to verify this statement. . . b) Resident #93 Review of the medical record for Resident #93 identified the continued use of the hypnotic, Ambien, since 09/28/11. The medical record contained no evidence of attempts at non-pharmacological interventions to assist in the management of the resident's [MEDICAL CONDITION]. The pharmacist completed a consultation report related to the use [MEDICATION NAME] 01/04/12. The pharmacist recommended adding an antidepressant such as [MEDICATION NAME], and [MEDICATION NAME]. Further review found the family nurse practitioner documented only no changes at this time, on 02/08/12. No rationale was given for not attempting the pharmacist's recommendations for decreasing/discontinuing the use of Ambien. As of 09/27/12, the use [MEDICATION NAME]. On 09/27/12, at approximately 9:45 a.m., Employee #119 (regional director of clinical services) stated she could find no other documentation related to the denial of the pharmacist's recommendations. . | 2015-09-01 |
| 9819 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 225 | E | 1 | 0 | L6DT11 | . Based on review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, and staff interviews, the facility failed to ensure all allegations of neglect and abuse were reported and/or investigated. Additionally, the facility failed to report the results of an investigation of an allegation of neglect within five (5) working days of an incident. The unreported allegations included: soiled clothing, bed linens, and furnishings, failure to provide mouth care, failure to provide a breathing treatment, bruising of unknown origin, failure to answer call lights, staff eating a resident's food, and failure to provide pain medication. The follow-up which was not reported was a complaint related to a failure to check blood sugar levels. Resident identifiers: #119, #5, #71, #116, #117, and #60. Facility census: 115. Findings include: a) Resident #119 The social worker (Employee #9) provided the past three (3) months of reportable allegations of abuse/neglect on 04/02/12, at approximately 11:00 a.m. The reportable allegations revealed an allegation involving Resident #119 which was reported on 12/27/11. The family's concern was regarding the facility's failure to check blood sugar levels. The facility did not have a five (5) day follow up which summarized the results of the investigation of this allegation of neglect. . . b) Resident #5 Review of complaint files revealed a complaint, dated 02/23/12, in which Resident #5's family alleged the resident vomited on 02/22/12 at 6 p.m., and still had vomit on her shirt and handrail on 02/23/12 at 10:45 a.m. The family also stated the resident had not received mouth care. The facility failed to report this allegation. During an interview with Employee #9 on 04/03/12, at approximately 3:45 p.m., she stated, "The last director of nursing took care of this, and I can find no other information on it." c) Resident #60 Within the complaint files was a complaint, dated 01/26/12, regarding this resident. A staff member from the therapy department stated Resident #60 told them her eggs were cold, and a girl ate the bacon off of her tray. The resident also told them she never received coffee. No evidence could be found the facility reported this allegation. While interviewing Employee #9 on 04/03/12, at approximately 3:45 p.m., she stated, "The last director of nursing took care of this, and I can find no other information on it." d) Resident #71 An allegation of neglect in the complaint file, dated 03/07/12, was lodged by this resident's sister. The sister stated the resident's bed was wet and her brother had blood on him. The facility failed to thoroughly investigate this allegation, and failed to report the allegation of neglect/abuse to the appropriate state agencies. On 04/03/12, at approximately 3:45 p.m., Employee #9 confirmed she had no other information on this allegation. She stated, "Employee #46 is now responsible for the reporting to the state agencies." e) Resident #117 This resident's family alleged, on 03/04/12, the resident did not receive pain medications for two (2) days. The facility failed to thoroughly investigate the allegation, and failed to report this allegation of neglect to the appropriate state agencies. Employee #9, on 04/03/12, at approximately 3:45 p.m., confirmed this was all the information she had on the allegation. She stated, "Employee #46 is now responsible for the reporting to the state agencies." f) Resident #116 On 02/27/12, the family of Resident #116 stated the resident was not receiving breathing treatments as ordered. They also stated the resident had unknown bruising around his lips and ears, and stated night shift had been rough with him. In addition, the family alleged night shift staff were not answering call lights. There was no evidence the facility reported this incident to the appropriate state agencies. During an interview with Employee #9, on 04/03/12, at approximately 3:45 p.m., she stated, "The last director of nursing took care of this, and I can find no other information on it." . | 2015-08-01 |
| 9820 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 243 | E | 1 | 0 | L6DT11 | . Based on review of family council meeting minutes, resident council meeting minutes, and staff interview, the facility failed to act upon the issues identified by the family council and the resident council. There was no evidence the concerns brought to the attention of the facility, by either group, were seriously considered and/or addressed. This practice had the potential to affect more than an isolated number of residents. Facility census 115. Findings include: a) Resident Council On 01/04/12, the resident council completed a grievance report stating scheduling was inappropriate. The facility's resolution to the concern was, "We schedule staff to census and state requirements of 2.25. Facility attempts to replace call-ins immediately. Running ads for new hires. Offering vacant shifts for bonus." The complaint was made by the resident council on 01/04/12, but was not addressed to the resident council on 02/14/12. b) Family Council Review of the minutes of a family council meeting, held on 03/20/12, revealed family members made various complaints: - Residents were not gotten out of bed - The facility's staffing level was inadequate - Resident rooms were not clean - Water and ice was not passed - Water and ice was out of residents' reach - Water was not given to those who needed help drinking - Incontinent residents were not changed in a timely manner - Call lights were not answered in a timely manner - Staff members passed call lights and did not answer them "stating not their residents." - Lotion was not applied to residents - Residents were not being walked - Medications were passed late - Catheter bags were hung incorrectly There was no evidence the facility gave serious consideration to any of the concerns expressed by the members of the family council. There was nothing to suggest the facility acted upon, or made any attempts to investigate the concerns expressed by the family council. Had the facility listened to the concerns, evaluated the concerns, and/or sought additional information, some of the concerns were allegations of neglect which required reporting to appropriate agencies as well as investigations. The facility's only resolution to the numerous complaints from the family council was to educate staff. . | 2015-08-01 |
| 9821 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 272 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a stage I pressure ulcer was assessed for one (1) of four (4) residents. The resident developed a stage I pressure ulcer which was not assessed according to the facility's policy on wound management. Resident identifier: #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The surgeon ordered a derma float air mattress, on 03/21/12, to promote wound healing. The order, dated 03/21/12, stated, "(physician name) ordered HILL ROM AIR MATTRESS FOR STAGE I ULCERS ON BUTTOCKS." The facility provided the resident with the air mattress. The assistant director of nursing (Employee #65) provided a copy of the facility's wound management policy on 04/03/12 at 9:40 a.m. The policy, dated January 2008, stated "Weekly Wound Rounds: The team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentation form. If a pressure ulcer fails to show progress toward healing within 2-4 weeks the team reevaluates the treatment plan to determine whether to modify the current interventions. Individual nurses should not alter the treatment plan without input from the interdisciplinary team and the physician." The medical record contained non pressure and skin condition reporting forms for non pressure related areas on the resident's coccyx. As of 04/03/12, the last documentation on this form was dated 03/07/12. At that time the area on the coccyx was red, but blanchable. On 04/03/12 at 9:00 a.m., an interview with the director of nursing ( DON), Employee #46, revealed the facility did not have any documentation regarding an assessment of the resident's wound which developed into a stage 1 pressure ulcer on 03/20/12. The DON said she could not find any further documentation regarding assessment/management of the wound after the area became a stage I pressure ulcer. . | 2015-08-01 |
| 9822 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 279 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to ensure two (2) of four (4) resident's care plans were updated to reflect the development of pressure ulcers. Resident identifiers: #30 and #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The care plan review occurred on 04/03/12. This review revealed the facility had not addressed the development of the stage I pressure ulcer. The director of nursing (Employee #46) was informed that the facility had not included this issue in the resident's care plan on 04/03/12 at approximately 9:30 a.m. On 04/04/12, at approximately 4:00 p.m., the minimum data set registered nurse (Employee #39) confirmed the resident's peripheral vascular ulcers were care planned, but the stage I pressure ulcer on the coccyx was not addressed in the care plan. . . b) Resident #30 Review of the facility's treatment administration record found this resident had stage II pressure ulcer wounds to her bilateral heels. Further investigation found the facility did not have a care plan regarding the provision of care and treatment of [REDACTED]. On 04/03/12, at approximately 12:45 p.m., Employee #65, the assistant director of nursing, confirmed the facility failed to develop a care plan for the wounds. . | 2015-08-01 |