CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11499 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 160 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to convey the funds, and a final accounting of those funds, within thirty (30) days after the death of the resident for two (2) of three (3) residents reviewed. Resident identifiers: #60 and #48. Facility census: 77. Findings include: a) Residents #60 and #48 The facility's resident funds accounts were reviewed at 8:30 a.m. on [DATE]. The balance of personal funds being held by the facility for two (2) of three (3) deceased residents reviewed had not been released within thirty (30) days after their deaths as required. Resident #60 passed away on [DATE]. Facility records show the balance of her personal account of $34.30 was not released until [DATE]. Resident #48 passed away on [DATE]. Facility records show the balance of her personal funds of $50.00 was not released until [DATE]. During an interview with the administrator (Employee #36) on [DATE] at 9:20 a.m., she confirmed these funds had not been conveyed within the required thirty (30) days. . | 2014-01-01 | ||
| 11500 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 279 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to develop a care plan to include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident #21 was admitted for a planned short rehabilitation stay and remained in the facility after rehabilitation goals had been met. No care plan was implemented to address the resident's discharge needs. The resident also was known to be at risk for falls at the time of admission, and no care plan goals and interventions were developed to address the risk. The resident did incur additional falls. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 1. When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained "multiple bilateral lower extremity fractures". Review of the physician's determination of capacity for this resident divulged that, at the time of admission (10/26/10), the resident's attending physician determined she did not have the capacity to understand and make health care decisions. This determination was changed on 01/03/11, when it was determined at that time that she did possess the capacity to make those decisions. An entry in social service (SS) notes, dated 11/09/10, stated: "D/C (discharge) plans are to return home." Again on 11/24/10, a SS note stated: "D/c plans remain to return home. No d/c date at this time." On 01/17/11, a SS note stated: "She plans to rehab & return home. MPOA (medical power of attorney) states resident will be LTC (long term care)." One (1) of two (2) minimum data set assessment (MDS) coordinators (Employee #65), when questioned on 04/25/11 at approximately 11:00 a.m. about the resident's plan to return to her home, stated the resident was occasionally confused, and Employee #65 did not feel the resident could care for herself at home, manage her diabetes, etc. She further stated she did not think the resident's family was willing to help her at home. The resident's care plan, when reviewed on 04/25/11, contained no mention of discharge and/or discharge planning for this resident on this document, which was most recently updated on 04/11/11. When reviewed again on 04/26/11, the resident's care plan had been updated to reflect the uncertainty of the resident's plan to discharge home. The facility's social worker (Employee #27), when interviewed on 04/26/11, confirmed she had not initiated any care plan related to discharge for this resident until 04/26/11. This employee further confirmed the resident's ability to make medical decisions was questionable and that a review of her capacity status had been requested. Recent calls to the resident's family / MPOA had gone unreturned, according to this employee. -- 2. The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and "yelled for help" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for "acute fractures". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, "I found resident sitting on floor between beds, she was yelling out, her alarm was on & working". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start "falling star" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. . | 2014-01-01 | ||
| 11501 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 280 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to revise the care plans of two (2) of forty (40) Stage II sample residents, when changes occurred in their health condition and/or treatment plan. Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. The resident's right leg was severely contracted, which caused the resident's right heel to push into the resident's buttocks. The staff had been applying heel protectors to the resident's heels to reduce pressure to these areas; the heel protectors were discontinued on 02/10/11, with no other intervention(s) added to address this unrelieved pressure against the right heel. The pressure on the heel from constant contact with buttocks resulted in a suspected deep tissue injury, which was identified on 04/03/11. At that time, the facility failed to identify this constant pressure as the cause of the pressure sore, and failed to revise her care plan to include measures to reduce / relieve this pressure until after the physical therapist was consulted on 04/19/11. Resident #41's care plan was not revised to reflect the application of a hand roll to address contractures of the resident's left hand. Facility census: 77. Findings include: a) Resident #28 Record review revealed Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. A review of Resident #28's minimum data set assessment (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 01/18/11, revealed the assessor identified, in Section G, that Resident #28 was totally dependent on staff for the performance of all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. In Section K, the assessor noted she did not have a significant weight loss either in the previous month or in the previous six (6) months. In Section M, the assessor noted she had no unhealed pressure sores and there were no pressure ulcers present on the prior MDS, although she was at risk for developing pressure sores in the future. Review of the Braden Scale assessment (for predicting pressure sore risk) dated 01/18/11, the resident scored "13", indicating she was at moderate risk for developing a pressure sore. A progress note recorded by the former MDS coordinator (Employee #63), dated 01/25/11, stated (quoted as typed): "Quarterly care plan conference held today. ... Currently skin is intact , receives preventative skin treatments Q (every) shift. Float heels when in bed, air mattress, and heel protectors. resident has multiple contracture to extremities, refuses daily to get OOB (out of bed), will agree to get out of bed on 3-11 shift approximately 2 times a week. ..." -- The resident's care plan, dated 09/16/08 to 08/04/10, identified the following problem statement (quoted as typed): "Potential for impaired skin due to fragile skin, history of impaired skin, incontinence, impaired mobility, at risk for UTIS (urinary tract infection),unstageable area to left heel." (A line was drawn through "unstageable area to left heel", followed by "D/C (discontinued) 10/26/10".) This problem statement was subsequently updated with handwritten entries as follows (quoted as written): - "Will return to Rt (right) side /p (after) repositioning and use of repositioning aides." (This entry was not dated or signed.) - "4-29-10 Open area on left buttocks." (This entry was subsequently marked as "resolved" on 06/01/10.) - "8-4-10 blisters to left inner big toe and right little toe outer aspect." - "8/8/10 Open blister on rt. shoulder." (This entry was subsequently marked through, with no date to indicate when this was discontinued.) - "4/1/11 I am At risk for excoriation under my breast." - "4/22/11 SDTI (suspected deep tissue injury) (R) (right) heel." (According to the NPUAP, a "suspected deep tissue injury" is defined as: "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.") The goals associated with this problem statement included (quoted as typed and/or written): "Resident will have intact skin through the next 90 days and will develop no UTIS. Area to left heel will reso;lve prior to next review. (This goal addressing the area to the resident's left heel was discontinued on 10/26/10, after the area was resolved.) ... 4/22/11 Will resolve SDTI (R) heel /s (without) complications through next review." The interventions associated with the above problem statement with its subsequent revisions included (quoted as typed and/or written): "Examine skin during bathing for signs / symptoms of irritation and/or breakdown. ... Assure proper positioning in/out of bed. Utilize pillows ect. as needed. Assess skin for S/S (signs / symptoms) of breakdowns, report to MD if so noted. ... OOB (out of bed) in geri-chair with cushion daily as tolerated. Turn and reposition as indicated. Heels up while in bed. skin prep to left heel twice daily for protection. Air mattress to bed to promote wound healing, ... Change and check for incontinence upon awakening, before and after meals, before bed and prn (as needed). ... Topical treatment to (R) heel as ordered." Notations on the care plan revealed the use of "(h)eel protectors while in bed" was discontinued on 02/10/11. -- A separate care plan, dated 04/04/11, contained the following "focus area" (quoted as typed): "I have SDTI to my (R) heel r/t (related to)[MEDICAL CONDITIONS] with multiple joint contractures, Hx (history of) ulcers, Immobility." The goal associated with this focus was: "The SDTI of my (R) heel will show signs of healing and remain free from complications through review date." The interventions planned to achieve this goal were: "I need to turn / reposition at least every 2 hours, more often as needed or requested. I need moisturizer applied daily and PRN to my skin. ... I require low air loss mattress to my bed. ... I require supplemental protein and nutritional supplements as ordered to promote wound healing. Administer treatments as ordered. ... Administer treatments as ordered and monitor for effectiveness (skin prep (R) heel as ordered). Assess / record/ monitor wound healing weekly. ... Monitor nutritional status. ... Monitor / document / report to MD PRN changes in skin status. ..." The care plan did not recognize as the causative factor of the pressure sore the constant pressure from the right heel's contact with the resident's buttocks, and there were no interventions to reduce / relieve this pressure. -- An interview with the director of nursing (DON - Employee #63), on 04/25/11 at 11:00 a.m., revealed the facility was told by "corporate" to discontinue all heel protectors, because research showed the heel protector did not help with eliminating pressure from the heel. Instead, the facility was using other methods, such as floating the heels off of the bed and pillows. The DON further stated the intervention for floating Resident #28's heels could not be achieved related to her lower extremity contractures. -- An interview with the physical therapist, on 04/25/11 at 12:00 p.m., revealed the resident received an evaluation related to a pressure (black) area on the resident's right heel. According to the physical therapist, "The right leg is very contracted and pushes against the resident's buttocks, causing pressure. We are treating the resident with pressure-relieving heel protectors which will prevent the heel from pushing against the resident's buttocks." -- An observation of Resident #28, on 04/25/11 at 2:10 p.m., found her in bed in her room. A nurse (Employee #52) removed the resident's blankets, and the resident was observed to have a dime-sized area of eschar on her right foot. The resident had padded heel protectors on both feet. The resident's right leg was severely twisted up around her back, with the right heel fixed against her buttocks. The left leg was also observed as severely twisted and fixed in position. Padded heel protectors were on the resident's feet. Employee #52 stated, "The resident is very difficult to move in bed. She refuses to get out of bed frequently and becomes very agitated when turned and repositioned." She further stated, "I just came on full time and before that I only worked part time. I really don't know much about the resident." The resident's care plan directed staff to float the resident's heels off of the bed; however, this observation revealed the resident's lower extremities were so severely contracted that it was not possible to float her heels off of the bed. According to the NPUAP, the presence of eschar on the resident's right heel (as seen by the nurse surveyor on 04/25/11) is consistent with the NPUAP's definition of an "unstageable" pressure sore: "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. ... Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." -- A review of the physical therapy evaluation dated 04/19/11 revealed, under the heading "Reason for Referral": "Contracture mgmt. (management), Splint / Orthosis; Compromised skin integrity". The long term goal for therapy was: "Upon completion of therapy, pt (patient) will tolerate positioning wedge x 2 hrs to decrease pressure of feet on buttocks." Under the heading "Other Observations" was: "There is a nickel-sized area on her posterior right heel. It is covered with black eschar with an irregular border and red periphery. It is dry." Under the heading "Positioning" was: "Recommendations made for Equipment: Nursing recommending positioning device to relieve pressure from right heel due to a pressure area developing from heel being placed against buttocks." Also under the heading was: "Pt lies on either side with UEs (upper extremities) and LEs (lower extremities) contracted up into flexion. Her LEs are contracted to the extent that her feet are being pressed against her buttocks." Review of the physical therapy weekly note dated 04/25/11 found, under the heading of "Justification for Continued Treatment": "Pt was provided with padded heel protectors which demonstrated a good fit. The original positioning wedge appeared to be too large and the order was cancelled. Pt is tolerating gentle ROM (range of motion) / stretching, but occasionally will note discomfort. Continue with ROM as tolerated and monitor use of heel protectors. Also, a gel cushion has been ordered to apply to her chair for further pressure reduction." -- An interview with the physical therapist, on 04/26/11 at 9:35 a.m., revealed a wedge was considered and was not ordered for the resident. The extra padded foot protectors were ordered and applied to keep the right heel from going against the resident's buttocks causing pressure. Some manipulations of the LE contractures allowed some extension to the contractures. The resident was unable to tolerate too much manipulation of the contracture. The physical therapist stated she was going to attempt to stretch as much as possible the contractures of the resident's lower extremities. -- A physician's progress note dated 04/15/11 stated: "(Resident #28) developed in early April developed an area on her right heel. Initially it measured 1.2 x 1.6 centimeters areas is blackish brown in color. It is suspected to be a deep tissue injury. She has severe contractures, probably in the entire facility her contractures are worse than anyone that we have. I believe this is unavoidable because of the severe contractures. She has positioning therapy. She has been referred to physical therapy. Her pre-[MEDICATION NAME] level is still below normal at 17.3. We increased her 2CalHN (nutritional supplement) to 3 ounces q.i.d. (four-times-daily) with MedPass. She is on ProSource, Magic Cup, and she has an air mattress to try to aid prevention of skin breakdown and healing of the areas that do breakdown." A physician progress notes [REDACTED]. integrity at that time. Similar physician progress notes [REDACTED]. -- A review of nursing notes, recorded immediately before and after the heel protectors were discontinued on 02/10/11, did not reveal evidence that staff recognized the resident's lower extremity contractures resulted in her right heel constantly pressing against her buttocks. The following entries were noted with respect to the resident's heels: - On 02/06/11 at 2:00 p.m. - "... Skin warm, dry, & intact. (Symbol for 'no') new area noted to skin. ..." - On 02/20/11 at 2:25 p.m. - "... Skin warm & dry, intact. Skin prep cont (continued) to heels. ..." - On 03/06/11 at 10:15 a.m. - "... Skin warm, dry & intact, skin prep to (B) (both) heels. ..." - On 03/13/11 at 3:00 p.m. - "... Remains on low air low mattress /c (with) (+) (positive) functioning & no bottoming out due to high risk for breakdown. Skin currently intact /c no pressure areas noted. ..." - On 03/20/11 (7-3 shift) - "... Skin assessment reveals (symbol for 'no') new skin issues." - On 03/27/11 (7-3 shift) - "... skin intact, (symbol for 'no') skin issues ..." - On 04/03/11 at 2:00 p.m. - "Resident's skin assessment completed. Right heel /c SDTI 1cm x 2 cm observed. Skin prep orders received and applied. ..." - On 04/04/011 at 10:30 a.m. - "(R) (right) heel /c SDTI ..." -- Review of the resident's physician orders [REDACTED]. - On 04/03/11 at 2:00 p.m. - "Skin prep to right heel every shift for two weeks then re-eval. Suspected deep tissue injury." - On 04/04/11 at 1430 (2:30 p.m.) - "Order clarification: Skin prep to both heels every shift. SDTI / [MEDICATION NAME] treatment." - On 04/05/11 at 5:00 p.m. - [MEDICATION NAME] level d/t (due to) Stage I wound." - On 04/06/11 at 1515 (3:15 p.m.) - "... Order clarification - [MEDICATION NAME] level of 4-6-11 for SDTI." No orders were received to address the underlying cause of the pressure sore until 04/19/11, when the following orders were received: - On 04/19/11 at 11:55 a.m. - "PT eval & treat." - On 04/19/11 at 11:55 a.m. - "PT services 3 x 1 wk x 4 wks for LE stretching / ROM & positioning devices to decrease pressure & improve LE positioning while in bed." -- b) Resident #41 Observation of Resident #41 revealed multiple joint contractures, with a Posey hand roll in use for contractures of the left hand. Review of the resident's current recapitulation of physician's orders [REDACTED]." Review of Resident #41's care plan revealed the presence of left hand contractures, but the care plan was not revised to address the use of the Posey hand roll. During interview with the director of nursing on 04/21/11 at 11:30 p.m., she agreed the resident's care plan did not mention using a Posey roll or other splinting device for the contractures of the left hand, noting that in the past this resident refused them, but in recent times she had not been resistive to its application. . | 2014-01-01 | ||
| 11502 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 323 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, observation, and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to care plan and/or implement measures to promote safety related to falls. Resident #21 was admitted to the facility on [DATE], after having been hospitalized for [REDACTED]. Interventions to promote safety related to falls were not addressed in her care plan until two (2) months after her admission, when the physician ordered a bed alarm on 12/28/10. Additional interventions (to include placing the resident's bed in a low position) were not added to the resident's care plan until the resident sustained [REDACTED]. When observed on 04/26/11, Resident #21 was observed to be asleep in her bed, but her bed was not in the low position as care planned. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained "multiple bilateral lower extremity fractures". The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and "yelled for help" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for "acute fractures". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, "I found resident sitting on floor between beds, she was yelling out, her alarm was on & working". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start "falling star" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. The resident was observed to be in bed asleep at 10:30 a.m. on 04/26/11. The bed was not in the low position. This observation was confirmed by a second surveyor at that time. | 2014-01-01 | ||
| 11503 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 285 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to assure a reassessment was completed for a resident who was approved for nursing facility placement for less than three (3) months and remained in residence after six (6) months. Resident identifier: Resident #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. Documentation found on page 5 of 6 of form PAS2000 for this resident disclosed, in Section #38 titled "Physician Recommendation", a nursing facility stay of less than three (3) months had been determined necessary for this resident. The resident had been at the facility for nearly six (6) months at that time. The facility's social worker (Employee #27), when interviewed on 04/25/11 at 1:15 p.m. following a review of the resident's record, confirmed the resident had not undergone reassessment, and the form PAS2000 had not been resubmitted following the initially approved three (3) month period. . | 2014-01-01 | ||
| 11504 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2010-09-23 | 311 | E | 5AUJ11 | . Based on record review and staff interview, the facility failed to provide daily restorative nursing services for residents designated to receives those services. Record review revealed specific written plans to meet specific goals for residents in the restorative nursing program. However, restorative aides were, at times, pulled to work the floor in the capacity of a nursing assistant due to staffing shortages, leaving the restorative nursing services undone. During interviews with certified nursing assistants (CNAs) conducted on 09/22/10, seven (7) of eight (8) CNAs interviewed reported they do not follow the restorative nursing plan; rather, they perform range of motion to restorative residents the same as they do to all dependent residents during the performance of activities of daily living. Resident identifiers: #10, #12, #49, #56, #57, #59, #61, #65, #70, #73, #77 #81, and #82. Facility census: 101. Findings include: a) Resident #10 Review of the Restorative Nursing Program (RNP) Flow Sheet, found in the restorative book for September 2010, revealed he was to "perform active assist range of motion (ROM), bilat (bilateral) upper ext (extremities) all joints 3 sets of 20 (twenty) reps (repetitions) daily." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - b) Resident #12 Review of the RNP Flow Sheet for September 2010 revealed Resident #12 was to receive "Active ROM (range of motion) ex (exercise) 2 sets 15 reps (repetitions) in seated position (heel / toe raises, seated marches, knee extension / flexion, hip abduction / adduction) daily". Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/7, 9/8, 9/9, 9/10, 9/12, 9/13/, 9/14, 9/15, 9/16). Resident #12 was also to "Ambulate /c (with) rolling walker - contact guard of 1 assist to daily tolerance / distance." Restorative staff documented having provided this service on only six (6) of the first 20 (twenty) days in September (9/7, 9/8, 9/9, 9/10, 9/15/ 9/16). - c) Resident #49 Review of the RNP Flow Sheet for September 2010 revealed Resident #49 was to receive "active assist ROM 3 sets 15 reps each (seated marches, knee ext while seated, hip abduction / adduction)" and "Ambulate /c rolling walker - min (minimum) assist of 1 (symbol for increase) to 50 ft or more as tolerated." Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September, with four (4) refusals. Dates documented for both plans were 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16. - d) Resident #56 Review of the RNP Flow Sheet for September 2010 revealed Resident #56 was to receive: "Bilat (bilateral) lower ext (extremity) - active ROM 2 sets x 15 reps ... (seated marches, hip abduction / adduction, knee extension / flexion, heel / toe raises - dorsal / plantar flexion)." Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to: "Ambulate /c rolling walker (10 - 30 ft) - verbal cue to keep walker @ correct distance in front of her." Restorative staff documented having provided this service on only three (3) of the first twenty (20) days of September, with three (3) refusals (9/4, 9/7, 9/8, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to have: "Active Assist ROM (R) (right) upper ext (extremity) - 3 sets 15 reps... Active ROM (L) (left) upper ext - 3 sets 15 reps." Restorative staff documented having provided this service on only seven (7) of the first 20 (twenty) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - e) Resident #57 Review of the RNP Flow Sheet for September 2010 revealed Resident #57 was to receive: "Active ROM - 3 sets 15 reps... passive ROM LUE (left upper extremity) and (L) hand - 3 sets 15 reps... wash & dry (L) hand - remove splint q (every) day - report any skin issues to nurse." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - f) Resident #59 Review of the RNP Flow Sheet for September 2010 revealed Resident #59 was to maintain bilateral upper extremity strength and "use 7 lb therapy bar during course of ADL (activity of daily living) - 3 sets - 20 reps or to tolerance." This treatment was to have begun on 09/21/10. During an interview with Employee #54 on 09/22/10 at 11:30 a.m., she said it was not begun on 09/21/10, as staff did not know where the therapy bar was kept in the physical therapy department. - g) Resident #61 Review of the RNP Flow Sheet for September 2010 revealed Resident #61 was to: "Ambulate up to 300 ft /c rolling walker - contact guard assist (may continue after resting) for (symbol for increased) ambulation if desired." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to have: "Bilat (bilateral) lower ext (extremity) 2 sets 15 reps AROM (active range of motion)... 2 lb ankle weight (seated marches, knee extension / flexion, hip abduction / adduction, dorsal / plantar circles... heel / toe raises." Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September on (9/4, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - h) Resident #65 Review of the RNP Flow Sheet for September 2010 revealed Resident #65 was to: "Ambulate 400 ft + (plus) /c supv (supervision) - no assistive device." Restorative staff documented having provided this service on eleven (11) of the first twenty (20) days of September (9/1, 9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). Also, she was to have: "AROM bilat lower ext - cues may be necessary (heel / toe raises, knee extension / flexion, hip abduction / adduction) 2 sets - 15 reps." Restorative staff documented having provided this service on only eleven (11) of the first twenty (20) days of September (9/1, 9/3, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 916). She was also to receive: "Active ROM bilateral upper ext 3 sets - 20 reps... verbal cues /c ADL's (activities of daily living) - dressing / grooming / toileting." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). - i) Resident #70 Review of the RNP Flow Sheet for September 2010 revealed Resident #70 was to have: "Left upper ext all planes active ROM 3 sets - 20 reps." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with one (1) refusal. - j) Resident #73 Review of the RNP Flow Sheet for September 2010 revealed Resident #73 was to: "Ambulate /c rolling walker - CGA (contact guard assist) 300+ ft ... Active ROM BLE ex (bilateral lower extremity exercise) - heel / toe raises, seated marches, knee extension, hip abduction / adduction... Active ROM ex (exercise) - bilat upper ext all planes 3 sets - 30 reps." Restorative staff documented having provided these service, which included two (2) days when the resident was out of the facility, on only nine (9) of the first twenty (20) days of September (9/1, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - k) Resident #77 Review of the RNP Flow Sheet for September 2010 revealed Resident #77 was to have" "Active ROM ex (L) upper ext 3 sets - 15 reps use 2 lb wgt (weight) if possible... Active assist ROM (R) upper ext 3 sets - 15 reps... Bilat lower ext active ROM 3 sets - 15 reps (ankle pumps, knee extension, hip flexion, seated marches, hip abduction / adduction." Restorative staff documented having provided these service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - l) Resident #81 Review of the RNP Flow Sheet for September 2010 revealed Resident #81 was to: "Ambulate /c rolling walker 150 ft min (minimum) contact guard assist... verbal cues to (symbol for increase) step length / stay inside walker." Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with four (4) refusals. - m) Resident #82 Review of the RNP Flow Sheet for September 2010 revealed Resident #82 was to have: "Active ROM - bilat lower ext - 3 sets 15 reps (seated marches, hip abduction / adduction, seated knee ext (extension)." Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to: "Ambulate /c rolling walker - contact guard assist of one to tolerance." Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days in September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - n) During an interview with a restorative aide (Employee #58) on 09/20/10 at 5:45 p.m., she stated that restorative services were provided for each resident seven (7) days per week. She said there was one (1) restorative aide who worked from 10:00 a.m. to 6:00 p.m., and there were two (2) restorative aides who worked the 7:00 a.m. to 3:00 p.m. (7-3) shift. She said two (2) restorative aides were pulled to work the floor today, leaving the other restorative aide to obtain weights on thirty (30) residents and then work 1:1 with another resident. For this reason, the restorative aides did not perform restorative nursing services today to all residents who to receive services - other than restorative dining in the dining room for five (5) residents; a nurse would be at the restorative table for the evening meal. She said she did not perform range of motion exercises or assist with ambulating any restorative residents in the hall today. - o) During an interview with a nurse (Employee #43) on 09/21/10 at 2:00 p.m., regarding all the "blanks" in the Restorative Book where nothing was documented to show restorative services were done on those days, she said a new program went into effect the beginning of September whereby copies of the RNP Flow Sheets for residents and their specific treatments are placed in the NA's (nursing assistant's) ADL (Activities of Daily Living) book for NAs to sign on days they provide restorative nursing services. - p) During an interview with another nurse (Employee #101) on 09/21/10 at 2:10 p.m., she said the nursing assistants do the restorative care on the 7-3 shift if the restorative aides get pulled to work the floor. - q) During interviews on 09/21/10 at 2:20 p.m. with nursing assistants who provided care today or yesterday to the following residents (Employees #31, #94, and #59), the aides were asked what restorative nursing services they provided and answers were as follows: - For Resident #31 - "walked him to the bathroom and to the chair", "got range of motion to the upper and lower extremities today for a total of 10 minutes - restorative did it." - For Resident #63 - "was taken to the bathroom and transferred back and forth to the commode" - For Resident #6 - "transferred from the bed to the chair, moved arms and legs about 10 minutes" - For Resident #56 - "took her to the bathroom about ten times" - For Resident #23 - "helped during bathing" - For Resident #10 - "walked to the bathroom twice" - For Resident #17 - "worked arms and legs when changed" - For Resident #82 - "walked her to the bathroom and back" - For Resident #49 - "walked to the bathroom twice" - For Resident #70 - "walked to the bathroom to the hallway and to the chair" - For Resident #81 - "walked him to the bathroom" - For Resident #66 - "walked to the bathroom" - For Resident #92 - "had range of motion to the upper extremities today for 10 minutes - restorative did it." - r) During an interview with Employee #43 on 09/21/10 at 3:15 p.m., she said the process for the CNAs to provide restorative care when the restorative aides were not available just started the first of September. She stated that the CNAs, nurses, and physical therapy have all met with inservices given, and all the CNAs should know how to do restorative nursing services, but perhaps not all know how to do it correctly yet. When asked, she said she believed the restorative aide positions were here to stay, but she was certain. However, they want to empower the CNAs to be able to do restorative nursing care as part of their daily duties. - s) During an interview with the director of nursing (DON) on 09/21/10 at approximately 5:30 p.m. regarding what nursing assistants said they were providing to restorative residents on days the restorative aides were absent or pulled to the floor to work as CNAs, she said it was probably just the "verbiage" they were unfamiliar, with as they have all received inservice education on restorative care. - t) During interviews with eight (8) nursing assistants (Employees #31, #27, #54, #55, #59, #94, #112, and #108) on 09/22/10 from 10:00 a.m. to 11:45 a.m. seven (7) of the eight (8) replied, when asked, that they do ADLs with residents who are in the restorative program and do range of motion to their joints during the process of performing routine care, just as they do for all dependent residents. They were in agreement that, when they sign on the Restorative Nursing Flow Sheet, they are signifying that range of motion was completed during their shift plus getting them up in a chair and/or walking them to the toilet if they are able. They were in agreement that the restorative staff perform lengthy ambulation per the restorative plan, although they (the CNAs) will walk a resident in the hall if he/she asks; and it is the restorative staff that does specific exercises (such as seated marches, etc., and exercises with repetitions and sets), not the CNAs. One (1) of the eight (8) CNAs said she does the exercises and repetitions according to the Restorative Nursing Plan, but she said she was not sure what hip abduction / adduction entails. Also, she was unable to describe what PROM and AROM entails. - u) During an interview with the staff development nurse (Employee #104) on 09/22/10 at 12:15 p.m., she reported the facility conducted a CNA class that ended in July with twelve (12) graduates, and five (5) of them are currently working at the facility. Also, the current CNA class graduates on 09/23/10, with six (6) students in that class and they test on 10/09/10. She said the next class begins on 09/29/10 with ten (10) students. She spoke of her desire for the facility to be able to hire and retain more CNAs. - v) Prior to exit for the day on 09/22/10 at approximately 4:00 p.m., the DON was informed of the continued concern regarding whether residents in the restorative nursing program were getting services as specified in the restorative nursing program flow sheet on days the restorative aides were absent or were pulled to work the floor as CNAs (instead of restorative aides). No further evidence was produced prior to exit on 09/23/10. | 2014-01-01 | ||
| 11505 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 152 | D | E5O711 | Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, "When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate." The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. . | 2014-01-01 | ||
| 11506 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 225 | E | E5O711 | Based on review of personnel records and other facility documents and staff interview, the facility failed to assure comprehensive screening was completed for three (3) of five (5) newly hired employees. Additionally, the facility failed to report an allegation of abuse involving one (1) resident to the State survey and certification agency and other officials in accordance with State Law. These deficient practices had the potential of affecting more than an isolated number of residents currently residing in the facility. Employee identifiers: #7, #14, and #76. Resident identifier: #2. Facility census: 29. Findings include: a) Employees #7, #14, and #76 1. Review of personnel records, on the afternoon of 05/29/0,9 found the facility did not obtain references from two (2) known previous employers prior to hiring Employee #7. 2. Further review found the facility did not obtain a criminal background check for the state of Ohio, when this state was listed as a previous residence of Employee #14. 3. It was also found the facility failed to access the Nurse Aide Abuse Registry to assure Employee #76 did not have findings of abuse or neglect registered with this state agency. Employee #32, who was assisting with review of the personnel records, was unable to provide evidence to show the required pre-employment screening for Employees #7, #14, and #76 was obtained by the facility. b) Resident #2 Review of facility records found, on 05/04/09, the daughter of Resident #2 sent an e-mail to the social services director alleging Employee #3 was "... smacking Mom's behind for wanting up at night to use the potty chair ... The woman may be teasing with Mom, but Mom is taking it as a punishment. Mom should not have to receive this treatment." Further review could find no evidence this allegation of abuse was reported to the State survey and certification agency or adult protective services in accordance with State law. An interview with Employee #32, on the afternoon of 05/29/09, confirmed this allegation had not been reported as required. . | 2014-01-01 | ||
| 11507 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 329 | E | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and pharmacist recommendation, the facility failed to assure the drug regimens of three (3) of ten (10) residents remained free from unnecessary drugs, used in excessive dose, for an excessive duration, and/or without indications for use. Resident identifiers: #1, #14, and #10. Facility census: 29. Findings include: a) Resident #1 1. Review of the medical record found Resident #1 was currently receiving [MEDICATION NAME] 50 mg twice-a-day (BID) and [MEDICATION NAME] 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge the pharmacist's recommendation. 2. Further review found the resident received [MEDICATION NAME] 1 mg at bedtime. A pharmacy recommendation, dated 01/20/08 (more than fifteen (15) months earlier) notified the physician that a gradual dose reduction needed to be attempted every six (6) months. The physician did not acknowledge the pharmacist's recommendation, and the resident remained on [MEDICATION NAME] 1 mg at bedtime. b) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses administered [MEDICATION NAME] 500 mg for a total of eight (8) days beginning at 2:00 p.m. on 04/13/09, and continued [MEDICATION NAME] mg for seven (7) days after receiving the laboratory report. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. . | 2014-01-01 | ||
| 11508 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 428 | D | E5O711 | Based on medical record review and review of a pharmacy report of irregularities for two (2) of ten (10) sampled residents, the facility failed to assure the pharmacist's recommendation for a gradual dose reduction of Ativan was acted upon by the physician. Resident identifiers: #1 and #14. Facility census: 29. Findings include: a) Resident #1 Review of the medical record found Resident #1 was currently receiving Lyrica 50 mg twice-a-day (BID) and Neurontin 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge or act upon the pharmacist's recommendation. b) Resident #14 Review of the medical record found a pharmacy's consult to the physician dated 04/22/09. The pharmacist notified the physician the resident was ordered MS (morphine sulfate) 30 mg BID on 04/06/09, in addition to a current order for Oxycodone 10/650 every six (6) hours as needed (PRN) for pain. The pharmacist noted the order for Oxycodone did not contain parameters for nursing as to when the PRN Oxycodone should be administered. The physician failed to acknowledge or act upon the pharmacy recommendation. . | 2014-01-01 | ||
| 11509 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 502 | D | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure laboratory services were obtained for one (1) of ten (10) sampled residents. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found the resident was administered antibiotics for treatment of [REDACTED]. The treating physician ordered a repeat urinalysis with urine culture on 04/12/09. Review of the medical record found no evidence the laboratory test was obtained. An interview with a member of the nursing staff (Employee #27), on 05/28/09 at 9:50 a.m., confirmed the facility had not obtained the ordered test. . | 2014-01-01 | ||
| 11510 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 505 | D | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the physician was promptly notified of laboratory findings for two (2) of ten (10) sampled residents. Resident identifiers: #14 and #10. Facility census: 29. Findings include: a) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days on 04/10/09. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses continued to administer both [MEDICATION NAME] 500 mg [MEDICATION NAME] mg after receiving the laboratory culture which indicated no bacteria growth after forty-eight (48) hours. The medical record contained no evidence the facility notified the physician of the laboratory results. An interview with a member of nursing staff (Employee #27), on the morning of 05/29/09, confirmed the facility could provide no evidence the physician was notified. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. The facility could provide no evidence the physician was notified in a timely manner of the laboratory results to assure Resident #10 received the appropriate antibiotic to treat her UTI in a timely manner. . | 2014-01-01 | ||
| 11511 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 309 | D | E5O711 | Based on medical record review and staff interview, the facility failed to assure appropriate follow-up nursing assessment was provided to one (1) of ten (10) sampled residents. Nursing staff documented Resident #10 experienced bright red bleeding from the perineal area with no evidence of continued monitoring or assessment. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found a 04/20/09 nursing note which documented the resident was having a small amount of bright red bleeding from the perineal area during her bed bath at 10:30 a.m. The nursing note documented that, upon assessment, the bleeding appeared to be coming from the urinary meatus. The medical record contained no further information concerning the bleeding from the resident's perineal area. The next nursing note was not written until the weekly note on 04/24/09. An interview with a member of the nursing staff, on the morning of 05/29/09, could provide no evidence the resident received further assessment or monitoring of the area. . | 2014-01-01 | ||
| 11512 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 312 | E | XJ0U11 | . Based on record review, resident interview, and staff interview, the facility failed to assure residents were provided personal hygiene as needed and as planned by the facility. Each resident had scheduled shower days twice weekly. Residents were randomly selected for review from each of four (4) halls and equally from 7-3 and 3-11 shifts. Two (2) of four (4) residents residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. These findings excluded any showers offered but refused by residents and marked on the ADL (activities of daily living) sheets as refused. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care- planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided. . | 2014-01-01 | ||
| 11513 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 353 | E | XJ0U11 | . Based on record review, resident interview, and staff interview, the facility failed to deploy sufficient direct care staff across all shifts and units to ensure residents received personal hygiene as needed and as planned by the facility. Record review revealed two (2) of four (4) residents (#43 and #66) residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. When interviewed, Resident #43 reported she wanted her showers but sometimes did not get them because staff was too busy. In confidential interviews, nursing assistants on both the 7:00 a.m. to 3:00 p.m. (7-3) shift and the 3:00 p.m. to 11:00 p.m. (3-11) shift reported they have not been able to complete showers as scheduled in the past month or obtain the assistance of a second staff member for turning and repositioning residents who were assessed as requiring the assistance of two (2) for bed mobility due to a lack of availability of staff. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care-planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided. | 2014-01-01 | ||
| 11514 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 281 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of "Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses" (revised 06/17/09), and medical record review, the facility failed to provide goods and services in accordance with professional standards of quality, by assigning a licensed practical nurse (LPN) to complete in-depth skin assessments (including making a determination regarding the staging of pressure ulcers), an act outside her scope of practice. This practice affected one (1) of ten (10) sampled residents (#145) with the potential to affect all residents with pressure sores. The facility also failed to assure that physician orders [REDACTED]. This practice affected one (1) of ten (10) sampled residents (#152) with the potential to affect any other resident with similar physician orders. Resident identifiers: #145 and #152. Facility census: 142. Findings include: a) Resident #145 1. An interview was conducted, on 01/06/11 at 3:40 p.m., with registered nurse (RN - Employee #187) related to the care and services provided to promote healing to former Resident #145. During this interview, Employee #187 requested the assistance of the wound nurse, Employee #127 (who was an LPN). While discussing the interventions that had been put into place for Resident #145, Employee #127 described her contribution to the assessment of pressure ulcers. The LPN reported, at 3:55 p.m. on 01/06/11, that she was responsible for all the pressure ulcers of residents on the A, B, and C units of the facility. She stated she measured the wound beds; identified / described the presence of any tunneling, drainage, and colors; and staged the wounds. When asked if she had received specialized training in the assessment and staging of wounds, Employee #127 stated she did not have any additional credentials such as a wound care specialist. - 2. The administrator was asked, on the afternoon of 01/07/11, for evidence that the LPN (Employee #127) had received training or education in assessing and staging pressure ulcers. The administrator was unable to provide any evidence that this LPN had received formal training beyond entry level. - 3. Review of "Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses" (revised 06/17/09), which was published jointly by the State's licensing boards for RNs and LPNs, found the following on page 6: "Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care. The Boards receive many questions about the LPN's role in the assessment component of the nursing process. While the law does not specifically address the issue of the LPN's role in the assessment process, the rule clearly places the responsibility for the analysis of the data on the RN..." Review of page 12 found a section entitled "Guidelines for Delegation of Nursing Acts To the Licensed Practical Nurse", which contained the following language: "1. Delegation of acts beyond those taught in the basic educational program for the LPN should be based on a conscious decision of the registered nurse. - Practice beyond entry level for the LPN should not be automatic nor should it be based solely on length of experience. 2. Practice beyond entry level must be competency based. - Competency based practice is defined by structured educational activities which include assessment of learning and demonstration of skills. 3. Records of educational activities designed to enhance entry level knowledge, skill and ability must be maintained and available to the RN making the decision. - The employer and the employee must maintain records which include an outline of the educational content and an evaluation of achievement of educational objectives and demonstrated skills..." - 4. An interview with the RN assessment coordinator (Employee #48), who was responsible for the completion of the minimum data set (MDS) assessment, was conducted on 01/07/11 at 5:15 p.m. via telephone. She agreed that she was responsible for completing the pressure ulcer assessment section of each resident's MDS. When asked how she determined the stage of pressure ulcers, she stated she retrieved that information from the facility's weekly wound tool. When asked if she personally assessed resident wounds prior to completing the assessment portion of the MDS and staging the wounds, she stated she did not assess the wounds in order to complete this section of the MDS. - 5. A follow-up interview with Employee #127 was conducted via speaker phone on 01/07/11 at 6:15 p.m., in the presence of the administrator and the director of nursing (DON). Employee #127 verified she completes the weekly wound tool and stages the wounds. When asked if she received assistance in doing this from the RN, she stated, "Very rarely do I have to ask about a wound." -- b) Resident #152 Review of Resident #152's medical record found that, on 12/21/10 at 4:15 a.m., the physician gave the following orders: "Hold pain medications, [MEDICATION NAME], ... [MEDICATION NAME] until BP (blood pressure) comes up. Monitor BP Q (every) 30 minutes." 1. With respect to holding these medications in the presence of low blood pressure, the order did not contain clear and specific instructions to the licensed nurses to indicate when the resident's blood pressure was high enough to prompt the nurses to restart the medications. An interview with the DON, on the afternoon of 01/05/11, confirmed this order should have been clarified by the nursing staff. 2. With respect to the on-going monitoring of the resident's blood pressure, the order did not contain parameters to indicate at what point the licensed nurses were to discontinue monitoring the resident's blood pressure at a frequency of every thirty (30) minutes. Review of the medical record found the licensed nursing staff followed the physician's orders [REDACTED]. . | 2014-01-01 | ||
| 11515 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 441 | D | XJ0U13 | . Based on random observation and staff interview, the facility failed to implement an infection control program which effectively helped prevent the potential spread of disease and infection in the facility. A staff member was observed to rinse a bed pan soiled with urine in the sink in a resident's bathroom. This same staff member also obtained drinking water from other sinks to fill residents' water pitchers. This was true for one (1) of ten (10) sampled resident. Resident identifier #105. Facility census: 142. Findings include: a) Resident #105 At approximately 11:30 a.m. on 01/04/11, Employee #33 was observed to assist Resident #105 off a bedpan. The NA (nursing assistant) emptied the urine from the bedpan into the toilet located in the resident's room. The NA then turned on the water in the resident's sink and rinsed the bedpan. This nursing assistant was previously observed filling Resident ' s water pitchers at others sinks. The NA, who was interviewed immediately following the observation, was asked what she thought about rinsing bedpans from the same sink that drinking water was obtained. The NA stated it was "gross" because the "urine splashes up". . | 2014-01-01 | ||
| 11516 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 501 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's medical director failed to assume responsibility for the coordination of facility-wide medical care. There was no evidence of ongoing collaboration by the medical director with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct continuing non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care. Additionally, the medical director failed to coordinate medical care by not assuring Resident #143 received timely physician visits, and failed to assume the care of Resident #152 when nursing staff contacted him for medication for the resident, instructing staff to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. These practices affected two (2) of ten (10) sample residents during the current survey and had the potential to result in more than minimal harm to more than an isolated number of facility residents. Resident identifiers: #152 and #143. Facility census: 142. Findings include: a) The facility has had continued non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care (F309) during the last three (3) survey events at the facility, beginning with a survey event that concluded on 09/01/10, resulting in findings of deficiencies in quality of care at a level of harm. There was no evidence of ongoing collaboration with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct this continuing non-compliance. (See also citation at F309.) - b) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, "This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file." The medical director had not assured this attending physician saw this resident in a timely manner. (See also citation at F387.) - c) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to, in part, to the medical director's failure to render assistance in obtaining the necessary medication. (See also citations at F309 and F425.) . | 2014-01-01 | ||
| 11517 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 387 | D | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of ten (10) sample residents received a physician visit in the facility at least once every thirty (30) days for the first ninety (90) days after admission. This resident, who resided in the facility from [DATE] until 12/17/10, had no face-to-face visits with his attending physician. Resident #143. Facility census: 142. Findings include: a) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, "This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file." . | 2014-01-01 | ||
| 11518 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 225 | D | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, review of facility documents, and staff interview, the facility failed to ensure two (2) of two (2) allegations of neglect / abuse were reported immediately to the State survey and certification agency and other officials in accordance with State law, and failed to thoroughly investigate the allegations of neglect / abuse. It was further determined that, due to the failure of the facility to report and investigate allegations appropriately, the facility failed to take appropriate corrective actions. The facility failed to immediately report one (1) allegation of neglect, when a staff member failed to assure Resident #81's bed was placed in the low position with landing strips (utilized to pad the floor) placed beside the resident's bed prior to leaving the resident unattended, in accordance with the resident's physician orders. The resident fell from her bed and sustained a [MEDICAL CONDITION] which required surgical repair. The facility did not report this allegation until three (3) days after the incident. The facility failed to report, investigate, or take appropriate corrective actions when Residents #117 and #52 made complaints to facility staff concerning Employee #5 on 08/26/10, and requested that she no longer provide care for them. Resident identifiers: #81, #117, and #52. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 was found on the floor of her room. The resident's bed was left in a high position with no ordered landing strips placed on the floor beside her bed. The resident was subsequently hospitalized with a [MEDICAL CONDITION] which required surgical repair. Further review of facility documents found the graduate nursing assistant (Employee #136), who had been assigned to provide care for the resident on the day of the fall, claimed to be unaware that the resident was to have landing strips beside her bed. Review of the medical record found a current physician's orders [REDACTED]. The facility's records showed this allegation of neglect was not reported to State agencies until 08/25/10, three (3) days after the incident. An interview with the licensed social worker (LSW - Employee #73), on 09/08/10 at 4:45 p.m., confirmed the facility did not report the allegation of neglect immediately to adult protective services and the State survey and certification agency as required. - b) Residents #117 and #52 During random interviews conducted with alert and oriented residents on 09/09/10, Resident #117 stated, at 8:45 a.m., that approximately two (2) weeks ago, she woke up at 2:00 a.m. and asked a nursing assistant (Employee #5) to assist her in getting up. The resident stated Employee #5 refused to assist her and told her that she had to stay in the bed. The resident stated she asked the nursing assistant from the other hall (Employee #89) to help her get out of bed, and this aide assisted her. The resident further stated that, after being assisted up and going into the hallway, Employee #5 pointed her finger at her and told her it would be a long time before she could go back to bed. This allegation was reported to the director of nursing (DON - Employee #10) at 9:10 a.m. on 09/09/10. She denied having prior knowledge of this incident. Review of the resident council minutes for 08/26/10 found a communication from a member of the activities department (Employee #84) to the DON at 4:15 p.m., which stated, "(Resident #117 and Resident #52) no longer want (Employee #5) to take care of them, they each have different issues regarding her care and I ask that u (you) please speak with them both." An interview with Employee #84, at 12:50 p.m. on 09/10/10, confirmed the residents were complaining about Employee #5. She stated this was a nursing issue and she had reported it to both the DON and the unit manager. The DON, when asked at 10:10 a.m. on 09/09/10 about the 4:14 p.m. communication on 08/26/10, stated that, when she received, it she assigned it to her unit manager, and the issue has now been reported. Review of the 09/09/10 reported allegation of neglect related to Employee #5 found the facility both reported the allegation and completed the five-day follow-up on 09/09/10. The investigation merely consisted of the unit manager's late entry nursing note dated 09/07/10. The document contained no attempts to determine the date the incident happened, no attempts to obtain statements from the residents or staff members who were either involved in the incident or were potential witnessed the incident. Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 06/30/10, assessed Resident #117 as being independent in cognitive skills for daily decision making with no deficits with long or short term memory, no indicators of [MEDICAL CONDITION], no mood problems, no behavioral problems, and being able to understand and make herself understood. The facility assessed the resident as requiring the extensive physical assistance of one (1) staff member with transfers. Review of the resident's current care plan, provided by the facility on 09/09/10, found under the problem of activities of daily living (ADL): "Resident is dependent with transfers with slideboard." The facility did not report or investigate potential allegations of abuse / neglect when informed of Residents #117 and #52's concerns on 08/26/10. Additionally, the nursing assistant (Employee #5) who was the subject of resident complaints continued to be assigned to care for Residents #117 and #52 when no attempts had been made that ensure it was safe to do so. . | 2014-01-01 | ||
| 11519 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 224 | G | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to ensure that goods and services were provided to prevent physical harm to one (1) of eight (8) sampled residents. Facility staff failed to assure that physician-ordered landing strips (utilized to pad / cushion the floor) were placed beside Resident #81's bed and failed to assure her bed was in a low position when left unattended on 08/22/10. Resident #81 fell from the bed and sustained a [MEDICAL CONDITION] requiring surgical repair. The graduate nursing assistant (Employee #136) responsible for the resident's care on 08/22/10 denied having knowledge of the requirement to place landing strips beside the resident's bed. The facility failed to put into place a system to orient new employees and temporary agency staff to the planned / ordered interventions to be provided to each resident. Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 fell from her bed to the floor. Facility staff documented the resident's bed was in a high to knee-high position with no physician-ordered landing strips present to cushion the floor beside the resident's bed. The resident sustained [REDACTED]. Review of the medical record found an active physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/10, found the resident was assessed as being severely cognitively impaired with impaired long and short term memory, and she required the extensive physical assistance of one (1) staff member for bed mobility, transfers, dressing eating, toilet use, and personal hygiene. The assessor also noted resident had sustained a fall in the thirty (30) days prior to the ARD. - Further review of facility information, concerning Resident #81's fall from bed on 08/22/10, found Employee #136 stated she had no knowledge that the resident was to have landing strips placed beside her bed. Review of the one-on-one education, conducted by the facility on 08/30/10, found the nurse informed the staff member: "...there are Kardex (sic) on every station. Please look at your resident's Kardex at beginning of shift to ensure you are aware of interventions in place to prevent falls and to give appropriate care." There was a lack of evidence to reflect the facility put procedures in place to inform other new staff and temporary agency staff of the care information located in the Kardex prior to providing care to assigned residents. - An interview was conducted with a nursing assistant employed by an outside temporary staffing agency (Employee #140) at 7:40 a.m. on 09/09/10. She was asked to show this surveyor where she would locate care instructions to assure that residents received appropriate care and services, such as, landing strips, bed height, splints, etc. Employee #140 walked behind the nursing station and retrieved the activity of daily living (ADL) book. When the documents were reviewed in the ADL book, it was noted that it merely contained a record of the residents' bowel movements, intake, bathing, etc. The book contained no instructions to staff concerning landing strips, bed height, splints, or other necessary care and services to be provided. When asked what a Kardex was, the aide stated that she did not know. A subsequent interview with the charge nurse on the unit (Employee #6) revealed she had not oriented the agency nurse aide as to where to locate the Kardex to access care information for residents. . | 2014-01-01 | ||
| 11520 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 514 | D | 9G3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to maintain the medical record of one (1) of eight (8) sampled residents in accordance with accepted professional standards and practices. Resident #81 sustained a fall resulting in a [MEDICAL CONDITION], but her medical record contained no progress note entries addressing the fall or the resident's subsequent hospitalization . Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found Resident #81 sustained a fall from her bed on 08/22/10 and suffered a [MEDICAL CONDITION] requiring surgical repair. Review of the medical record found no nursing progress note or other documentation of the resident's fall and subsequent transfer to the hospital. An interview with the director of nursing (DON - Employee #10), on 09/10/10 at 4:00 p.m., confirmed the medical record did not contain progress notes or any other documentation of the resident's fall and subsequent transfer to the hospital on [DATE]. | 2014-01-01 | ||
| 11521 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 242 | D | 9G3Y11 | . Based on review of resident council minutes and staff interview, the facility failed to assure one (1) random resident with a sample of eight (8) residents was afforded the right to choose bathing schedules consistent with aspects of his life in the facility that were significant to him. Resident identifier: #25. Facility census: 118. Findings include: a) Resident #25 Review of resident council minutes for 06/23/10 found Resident #25 requested that he be provided showers three (3) times a week. The response from the facility stated, "Not staffed for 3 showers per week." Under discussion of old business for the 07/26/10 resident council meeting, the minutes documented, "We are not staffed to give residents 3 showers a week." An interview with the administrator, on 09/09/10 at 9:10 a.m., revealed the wishes of the resident should have been honored. . | 2014-01-01 | ||
| 11522 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 241 | D | 9G3Y11 | . Based on observation, the facility failed to assure one (1) of eight sampled residents (Resident #96) was provided care in a manner that maintained her dignity while being transported through the hallway to the shower. Resident identifier: #96. Facility census: 118. Finding include: a) Resident #96 Random observations of the facility, on 09/08/10 at 4:10 p.m., found a staff member transporting Resident #96 through the hallway on a shower chair. The resident was seated on a commode-seat type shower chair. The staff member had placed a sheet around the top of the resident but failed to assure the resident's bottom was covered. The resident's unclothed buttocks were visible beneath the chair as the staff member pushed her down the hallway. This practice was brought to the attention of the unit manager (Employee #53), who obtained a sheet from the clean linen cart in the hallway and assured the resident was adequately covered. . | 2014-01-01 | ||
| 11523 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 364 | E | 9G3Y11 | . Based on observation, resident interview, and staff interview, the facility failed to assure the evening meal served on 09/08/10 was prepared in a manner that assured the food was palatable and attractive. This deficient practice affected more than an isolated number of residents receiving an oral diet. Facility census: 118. Findings include: a) Random observation of the evening meal, on 09/08/10, noted residents were served two (2) mounds of a grey-white gelatinous substance containing green flecks. It was noted that none of the residents eating in their rooms consumed the substance. When asked how the evening meal tasted, a resident (who wished to remain anonymous) described the taste as "Yucky". Another resident stated that it smelled like dog food. An interview with the dietary manager (Employee #16) was conducted at 6:25 p.m. on 09/08/10. When inquiry was made as to what the two (2) mounds of green-flecked substance served to residents were, she stated, "Turkey Tetrazzini." She stated the broccoli was overcooked due to the cook having to take her test and not getting back in time. She agreed the meal did not smell or look appetizing. . | 2014-01-01 | ||
| 11524 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 314 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was "large and foul-smelling" and the odor was "overpowering"; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. The nursing admission evaluation, dated 07/14/10, identified the resident was admitted with a Stage II pressure sore on the coccyx area measuring 5 cm x 4 cm x 0.2 cm, a Stage I pressure sore on the right hip measuring 2 cm x 2 cm, and a Stage I pressure sore on the left heel measuring 5 cm x 6 cm. On 07/14/10, the physician ordered the following treatment to the Stage III pressure sore on the coccyx: "Stage III coccyx: Cleanse q3d (every three days) /c (with NSS (normal sterile saline). Apply [MEDICATION NAME] Aq. Cover /c [MEDICATION NAME] dsg (dressing)." On 07/15/10, the order was changed to: "Cleanse area /c NSS. Apply [MEDICATION NAME] (white). Cover /c [MEDICATION NAME]. Change dressing Q3D (every three days) & PRN (as needed)." A review of the resident's comprehensive care plan, with an initiated date of 07/15/10, revealed the following problem statement: "Stage I on right hip, left heel and stage (sic) III on coccyx related to recent hospitalization secondary to refusing to eat, drink, diabetes, mobility, contractures, impaired mobility (sic), incontinence." The goal associated with this problem statement was: "Skin will heal within the limits of the disease process." Interventions intended to assist the resident in achieving this goal included: " ... Evaluate and record wound status per facility guidelines until healed. ... Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify family / responsible party of skin condition. ..." - 4. A late entry in the skin progress notes, dated 07/15/10 (for 07/14/10), stated, "Res (resident) admitted on [DATE] /c (with) diagnosis (sic) of UTI, [MEDICAL CONDITION], dementia,[MEDICAL CONDITIONS], TIA ([MEDICAL CONDITION]), contractures of upper & lower extremities. She had a Braden (scale) of 9 on admit (sic) very high risk for skin breakdown. Also not eating / drinking at hospital. She was admitted /c a Stage I on Right hip 2 x 2 red area, not open, PUSH = 6. Stage III on coccyx - 5 x 4 x 0.2 20% slough /c 80% granulation, no odor, no drainage, no swelling, no c/o (complaints of) pain /c tx (treatment). PUSH score = 12, also has a Stage I on left heel 5 x 6 , PUSH score = 10. Tx order. ... Enc (encourage) to eat & drink. ..." A skin progress note, dated 07/21/10, stated, "Wound rounds completed. DCD (director of care delivery) & wound nurse on rounds. (R) (right) hip 1 x 0.2 PUSH = 3 Stage I - coccyx 0.8 x 3.0 x 0.2 D (depth) PUSH = 8 Stage III - (LE) (left) heel 4 x 6 PUSH = 9 Stage I. Coccyx - 75% slough / 25% granulation, 0 (no) odor, 0 drainage, 0 swelling, 0 s/s (signs / symptoms) infection - tolerated tx well. ..." A skin progress note, dated 07/29/10, stated, "Wound rounds completed. Late entry (for 07/28/10). DCD ' s, DON (director of nursing), wound nurse, dietary, therapy present. (R) hip - 0.8 x 0.5 Stage I PUSH = 2, (L) heel - 3.0 x 5.0 Stage I PUSH = 9, coccyx - 2.8 x 0.7 x 0.3 Stage II PUSH = 7, 10% slough 90% granulation, 0 odor, 0 drainage, 0 s/s inf (infection) 0 s/s pain. ... Cont /c ordered tx." A skin progress note, dated 08/04/10, stated, "Wound rounds completed. DON, DCD ' s, wound nurse & therapy present. (R) hip 1.4 x 1.0 Stage = I PUSH = 5. (L) HEEL 2.0 x 3.0 Stage = I PUSH = 7. Coccyx 7.0 x 7.0 x 0.8 unstageable PUSH = 14 50% necrotic tissue, 25% slough, 25% granulation. 0 odor, 0 drainage, 0 s/s inf. 0 s/s pain. ... Cont /c ordered tx." From 07/28/10 to 08/04/10, the pressure sore on Resident #115's coccyx increased in size and was no longer able to be visualized for staging due to the presence of necrotic tissue, although the wound care nurse documented there was no odor, drainage, or signs / symptoms of infection. The Stage I pressure sores or the resident's right hip and left heel did not open or change during this time. - 5. A review of the nursing notes, from 07/15/10 until 08/07/10, did not contain any assessment of the resident's pressure sores or documentation to reflect identification of any odor or other signs / symptoms of infection in the pressure sore on the resident's coccyx. - 6. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 7. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." A hospital follow-up note, dated 08/26/10, stated: " This patient had a large decubit that was debrided and getting wound VAC (vacuum-assisted closure) treatment. The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 8. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." - 9. An interview with the wound care nurse, a registered nurse (RN - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when the pressure sore on Resident #115's coccyx was assessed to have increased in size on 08/04/10 and was not able to be visualized for staging due to the presence of necrotic tissue, she did not call the physician. She further stated she was new to the position and relied on some of the other nursing staff to tell her what she needed to do concerning the pressure sores. She also stated that, now, if a resident's pressure sore changed as Resident #115's did, she would call the physician immediately and schedule the resident with the wound clinic. She stated she works during the week and, after she leaves the facility each day, the floor nurses are responsible for the treatments. The floor nurses are also responsible for the treatments on the weekends. - 10. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker went into the emergency room . She stated, "The odor from the pressure sore was overpowering. I could not stand the smell. The emergency room nurses took pictures of the pressure sore on the resident's coccyx. It was large and foul smelling." She further stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." - 11. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 12. The resident was admitted to the nursing home on 07/14/10, with a Stage III pressure sore on the coccyx. On 08/04/10, the pressure sore became larger in size and was no longer able to be visualized for staging due to the presence of necrotic tissue; neither the resident's MPOA nor the attending physician was notified of the deterioration in the status of this pressure sore. (See citation at F157.) On 08/07/10, the resident's MPOA asked that the resident be sent to the hospital. Upon arriving at the hospital, the pressure sore was found to be overwhelmingly malodorous and severely infected; however, the nursing notes in the resident's medical record at the nursing facility failed to identify the presence of any odor or signs / symptoms of infection prior to her transfer to the hospital. During the resident's second hospital stay, she required treatment with intravenous antibiotics related to the infected wound, and the wound subsequently received surgical debridement. . | 2014-01-01 | ||
| 11525 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 327 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... " According to a Transfer Summary Report hemodynamically stable". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. Upon admission, the physician ordered a "no added salt", pureed diet with "level II fluids" (honey-thick liquids). According to the resident's weights and vitals summary, her weight on admission (07/14/10) was 130.0# and her height was 63 inches. The diet order was changed to mechanical soft with pureed meats and nectar-thick liquids on 07/20/10. - 3. A nutrition risk assessment, completed by a registered dietitian (RD) on 07/21/10, identified Resident #115 as being at HIGH RISK (score of 8 or higher), with a total score of 16. The RD calculated the resident's total fluid needs as 1737 cc/day. The resident's risk factors included an average intake of 33% at meals during a 7-day observation period, dementia, an [MEDICATION NAME] level of 2.7 (residents with [MEDICATION NAME] of less than 3.0 are at high risk), and one (1) Stage III pressure sore on the coccyx (with Stage I pressure sores also noted on the right hip and left heel). The RD recommended the addition of "Med Pass Supplement 2.0 60 ml 4 x day" on 07/21/10 to provide additional calories and protein for wound healing. On 07/27/10, the physician ordered: "Dietary consult - res(ident) not eating. ..." On 07/28/10, the RD noted, "Consult for res refusing to eat and wt (arrow pointing down) (sic) Res current wt 9-25-10 90.6 (pounds) /s (without) boots verified by re-wt. Boots weighed = 1# each. Res wt 7-23-10 98.2# wt 7-22-10 99.4# wt 7-18-10 127.4#. 130# 7-14-10. (Arrow pointing down) 39.4# / 30% / since adm (admission). Wt quest (questioned) on admit. Res has been refusing to eat per Nsg (nursing). Res current diet NAS mech soft, pureed meats & nectar liquids. Res avg (meal intake) 13% x 7 days (arrow pointing down) from 33% last review 7/21/10. Res currently receiving Med Pass 2.0 60ml 4 x day to supplement diet. Staff stated res consumed ice cream well 7-27-10 Rec (recommend) to add magic cup 1 x day at afternoon snack to provide 300cal/9g protein. Will contact POA to updated likes & dislikes. Will continue to encourage meal intakes." On 07/29/10, the RD noted, "Update (sic) res has started to consume meals better per Nsg (nursing). Nsg stated res will consume bite if presented /c (with) ice cream in between bites. ... D/T (due to) res intakes at meals are improving recommend to add Benical to lunch tray to help meet res needs. No further recommendations at this time. ..." While the RD was addressing the resident's weight loss and nutritional needs on a periodic basis, there was no mention of whether the resident was meeting her daily fluid needs. - 4. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the need to monitor the resident's hydration status, in view of the fact that her final [DIAGNOSES REDACTED]. - 5. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 6. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration. A review of all problems, goals, and interventions identified on the 14-page care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. Nursing notes indicated, beginning on day of admission, that resident would refuse to eat by refusing to open her mouth. The resident would eat for the MPOA on visit to the facility. A nursing note, dated 07/25/10 at 10:30 a.m., revealed, "... Staff able to get 2 bites of brfast (breakfast) & 60 ml of fluid into resident this am (morning)." On 07/27/10 at 10:00 a.m., a nursing note revealed, "... Res conts (continues) to ref (refuse) to eat / drink ... Res conts to allow food / liq (liquid) to run out of mouth." - 8. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 9. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 10. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." She further stated, "I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection." - 11. There was no evidence to reflect the facility had routinely assessed / monitor Resident #115's hydration status / fluid balance for signs / symptoms of dehydration with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. - 12. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 13. In an interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., she stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." . | 2014-01-01 | ||
| 11526 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 309 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide care and services necessary to attain or maintain the highest practical level of physical well-being for one (1) of twelve (12) sampled residents. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, severe dehydration, and an infected pressure sore. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in her hydration status, quantity and quality of her urinary output, and/or presence of signs / symptoms of UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: "Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations." The goals associated with this problem statement were: "Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction" and "No acute infection". The interventions intended to assist the resident in achieving these goals were: "Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care." - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found no evidence of periodic assessment or monitoring of the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI. The nursing notes did, however, note the resident was refusing to open her mouth and was not eating and/or drinking. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. Patient was also given IV antibiotic, [MEDICATION NAME] 1 gram daily and [MEDICATION NAME] 250 mg IV daily. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute on [MEDICAL CONDITION]. ..." - 9. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." She further stated, "I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection." - 10. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 11. There was no evidence to reflect the facility conducted periodic assessment or monitoring of the resident's hydration status, of the quality or quantity of the resident's urinary output, or for the presence of signs / symptoms of a UTI with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. . | 2014-01-01 | ||
| 11527 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 157 | D | GVP311 | . Based on record review and staff interview, the facility failed, for one (1) of twelve (12) sampled residents, to notify the resident's medical power of attorney representative (MPOA) and attending physician when the status of the resident's pressure sore significantly declined. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 A review of the facility's weekly skin report for Resident #115, dated 08/04/10, found: "The coccyx measurement is not able to be staged." The pressure sore was described as measuring 7 cm x 7 cm x less than 0.8 cm with eschar. This was a significant change from the previous week when, on 07/28/10, the pressure sore on the resident's coccyx measured 2.8 cm x 0.7 cm x 0.3 cm and no eschar was present. A review of nursing notes, on 08/04/10, did not find evidence to reflect either the physician or the resident's MPOA was notified of this significant decline in status of the resident's pressure sore. An interview with the wound care nurse (a registered nurse - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when on 08/04/10 the resident's pressure sore was assessed to be larger and was not able to be staged due to the eschar, she did not call the physician or notify the MPOA. . | 2014-01-01 | ||
| 11528 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 225 | E | GVP311 | . Based on record review and staff interviews, the facility did not ensure that four (4) of eight (8) resident concern forms reviewed, containing allegations of resident abuse / neglect involving nursing assistants, were reported to the State nurse aide registry. Resident identifiers: #115, #116, #117, and #20. Facility census: 114. Findings include: a) A review of the facility's complaint file revealed four (4) resident concern forms containing allegations of resident abuse / neglect which involved nursing assistants. These allegations of abuse / neglect were reported to the facility by family members and residents as follows: 1. A concern form, dated 07/20/10, stated the medical power of attorney representative (MPOA) of Resident #115 reported finding the resident lying wet with food on her clothes. 2. A concern form, dated 08/21/10, stated Resident #116 "stated she wanted to use BSC (bedside commode) but was told by 11-7 (night shift staff) that she needed to use the bedpan - 'that it's our protocol'. When she used the bedpan, the bed got wet. Res (resident) states only the top sheet was changed & the fitted sheet was still wet. When she told the CNA (certified nursing assistant) the bottom sheet was still wet, res says CNA said 'It's not wet unless you peed again' then (symbol for 'checked') the sheet & told res is was dry. Later res says she was cold & asked for a blanket. States CNA took her temp (97.1) & was told she 'didn't need a blanket.' Res was upset enough to tell (name of nurse) that she was ready to sign out AMA (against medical advice) the next morning. ..." 3. A concern form, dated 08/21/10, stated, "... Res (Resident #117) said 'I'm not one to complain' then hesitated. When asked what the problem was, he said 'You know. Night shift.' I asked what happened. Res stated 'When I had my light on, they came in & said 'What do you want now.' Res inferred it was said in a (sic) unpleasant tone of voice. Res then said CNA turned off the light & left the room." 4. A concern form, dated 07/15/10, stated, "Resident (#20) upset this AM (morning) stated that NS (night shift) ref (refused) to assist to BSC. Resident stated that NS staff told her that they could not get her OOB (out of bed) to BSC D/T (due to) only 3 staff & she requires 2 ppl (people) to do. Resident state (sic) this is a dignity issue. 'Why can't they not stand & pivot?'" - An interview with the assistant director of nursing (ADON - Employee #23), on 09/02/10 at 3:05 p.m., revealed she was in charge of reviewing the complaints and reporting allegations to the appropriate State agency(ies). She further stated the four (4) complaints with the allegations of abuse / neglect were investigated by her and were not submitted to the State agency. She stated she talked with the nursing assistants involved but did not submit the allegations to the State nurse aide registry. - In an interview on 09/02/10 at 4:30 p.m., Resident #20, who was alert and oriented with the capacity to understand and make her own health care decision, stated she had asked an aide to assist her to the bedside commode and the aide refused. The resident knew who the aide was, but would not tell the surveyor. The resident stated she had told the facility's investigating nurse the name of the aide. She further stated, "This was a dignity issue." . | 2014-01-01 | ||
| 11529 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 155 | D | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only "comfort measures", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select "comfort measures", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 5. Review of the nursing notes revealed an entry, dated 07/18/10 at 3:50 p.m., stating, "... (Resident) Resting in bed until lunch. POA (power of attorney) in. Upset that her instructions (sic) not followed. Wants resident up prior to BRK (breakfast). ... This nurse was under the impression that this resident was to stay in bed & that she was comfort measures. Many CNA's (certified nursing assistants) also were of similar belief. ..." In a progress note dated 08/01/10, the physician stated, "Pt's (patient's) PO (oral) intake poor but pt's POST form does not allow any tube feeding. ... Plan - continue comfort measures. ..." - 6. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 7. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m. revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." - 8. The facility failed to ensure all staff was aware of and honored this resident's advance directives. . | 2014-01-01 | ||
| 11530 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 279 | D | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to develop a comprehensive care plan for one (1) of twelve (12) sampled residents describing the services to address all medical and nursing needs that were known to the facility. Resident #115 was admitted to the facility following a hospital stay during which she was treated for [REDACTED]. No care plan was developed to address the need for ensuring the resident maintained adequate hydration status / fluid balance and did not acquire a repeat UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found multiple entries reporting the resident was refusing to open her mouth and was not eating and/or drinking. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: "Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations." The goals associated with this problem statement were: "Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction" and "No acute infection". The interventions intended to assist the resident in achieving these goals were: "Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care." A review of all problems, goals, and interventions identified on the 14-page comprehensive care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." . | 2014-01-01 | ||
| 11531 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-11-03 | 280 | D | GVP312 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and/or revise the comprehensive care plan when the health care status and care needs changed for three (3) of fifteen (15) sampled residents. Resident identifiers: #4, #7, and #11. Facility census: 113. Findings include: a) Resident #4 A review of the medical record revealed Resident #4 was an [AGE] year old female admitted on [DATE] with multiple diagnoses. She was re-hospitalized shortly after admission and readmitted to the facility on [DATE]. Her attending physician ordered "Comfort Measures Only" on 10/15/10, due to a decline in her health care status and the recent [DIAGNOSES REDACTED]. The nursing notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"just wanted to go to sleep". A review of the resident's care plan revealed there were no goals set and no nursing interventions to address the "End of Life Care" needs of this resident. During an interview with one (1) of the assistant director of nurses (ADON - Employee #3) at 2:40 p.m. on 11/02/10, she acknowledged these needs should have been addressed when the "Comfort Measures Only" order was written on 10/15/10. At 3:20 p.m. on 11/02/10, Employee #3 also confirmed there was no care plan revision addressing the resident's "End of Life Care" needs. -- b) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was recently hospitalized and readmitted on [DATE]. On 10/22/10, a suprapubic catheter was placed to aid in the healing of a pressure ulcer on the coccyx, a skin tear of the rectum, and the chronic UTIs. A review of the clinical record, on 11/02/10, failed to find evidence of a revision of the comprehensive care plan to include goals and nursing interventions for the care of the suprapubic catheter. There was also no interim plan of care established. The nursing notes on 10/27/10 documented there was urine seepage into the resident's adult incontinence brief, indicating that additional care was needed by direct care staff. During an interview with the director of nursing (DON - Employee #2) and both ADONs (Employees #3 and #4) at 12:40 p.m. on 11/02/10, they acknowledged, after reviewing the resident's current care plan, that a revision to address the presence of the suprapubic catheter had not been done. At 1:00 p.m., the Employee #3 returned, after checking the care plan books and the computer, and verified that the care needs associated with the presence of Resident #7's suprapubic catheter were not addressed in either the comprehensive or interim care plan. -- c) Resident #11 A review of the medical record revealed Resident #11 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Her current comprehensive care plan, which was initiated on 08/03/10 and revised on 08/12/10, stated she was "At risk for injury r/t (related to) fall due to impaired balance / poor coordination, [MEDICAL CONDITION].". The goals associated with this potential problem were to "minimize" falls and/or injuries. The nursing interventions to meet these goals were: "Assess for fall risk and reassess as needed; Bed in low position"; and Provide assist to transfer and ambulate as needed." The nursing notes and an incident report related the resident sustained [REDACTED]. She sustained a laceration and was transported to the emergency room for sutures and a brain scan. The resident assessment protocol (RAP), completed by the nurse (Employee #4) on 10/11/10 stated a care plan was to be "initiated / revised" to address this. However, review of her care plan found no evidence of any revisions to prevent future falls, and there were no interventions addressing the safe use of the wheelchair. During an interview with the DON and both ADONs at 12:40 p.m. on 11/02/10, Employee #4 verified she had stated in the RAP that the resident's care plan would be reviewed / revised. At 1:30 p.m., the Employee #3 presented a copy of the RAP and acknowledged there had been no changes to the care plan after the resident's fall with injury. . | 2014-01-01 | ||
| 11532 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-11-03 | 514 | D | GVP312 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure an accurate and complete medical record by failing to transcribe a physician's phone order into the correct locations on the medical record which resulted in confusion during the investigation of a potential medication error in the treatment of [REDACTED]. Resident identifier: #7. Facility census: 113. Findings include: a) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female who received [MEDICATION NAME] daily for control of a [MEDICAL CONDITION] disorder. A recent hospitalization resulted in new medication orders when she was readmitted to the facility. When readmitted on [DATE], the physician ordered: "[MEDICATION NAME] (125 mg/5 ml) 7.5 ml TID (3 times daily) PO (by mouth) and [MEDICATION NAME] 5 ml Q HS (at bedtime) PO." On 09/30/10, these orders were changed. All previous [MEDICATION NAME] orders were discontinued, and the physician ordered: "[MEDICATION NAME] 7.5 ml @ 8:00 a.m.; 5 ml @ 12:00 p.m.; and 7.5 ml @ 4:00 p.m. PO." On 10/21/10, the laboratory results showed a drop in the resident's serum [MEDICATION NAME] level, and when the physician was notified, documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] (125 mg/5 ml) 5ml Q HS PO." There was no evidence in the physician's orders [REDACTED]. During an interview with the nurse (Employee #7) at 2:30 p.m. on 11/02/10, she stated, after reviewing the record, that she was the nurse who had reported the laboratory values to the physician's office and received the new order, which she had placed on the MAR, but she had failed to transcribe the order onto the physician's orders [REDACTED]. | 2014-01-01 | ||
| 11533 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2010-09-28 | 441 | D | QQ4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: "1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10." Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - "F/C patent to leg ..." - On 07/27/10 - "F/C patent to leg drainage bag. Orange urine noted ..." - On 07/28/10 - "F/C patent to drainage on leg bag. Some leakage noticed but good flow ..." - On 07/30/10 - "Cath was removed yesterday R/T (related to) burning and leaking ..." During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/03/10, found no growth of MRSA at that time, although the culture was positive for Morganella morganii. On 08/26/10, the physician ordered, "Discontinue Isolation." - c) In an interview at approximately 3:00 p.m. on 09/28/10, Employee #2 (the registered nurse who has responsibility for the infection control program at the facility) identified that Resident #27 should not have resided in the room with Resident #90 after the indwelling urinary catheter was inserted into Resident #27 (as this created an open portal for entry by infectious organisms). Employee #2 presented a copy of a reference she used in her facility for MRSA. The reference material came from the following Internet site: . The reference material stated the following: "Contact precautions must be used when a resident is colonized or infected with MRSA in any site other than the nares .... Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. "Contact precautions consist of the following components: "Contact precautions must be used when a resident is colonized or infected with MRSA IN ANY SITE OTHER THAN THE NARES ... Contact precautions consist of the following components. "1. Room placement and Activities "- A resident who is colonized or infected with MRSA at any body site other than the nares should be placed according to the following scheme: "-- Most Desirable: A private room or cohorting with another resident who is colonized / infected with MRSA. "-- Less Desirable: A room with another resident who has intact skin and no 'tubes' (invasive feeding tubes, tracheotomy tubes, any type of intravascular line, any type of indwelling urinary drainage tube, or any other tube or device that breaks the skin or enters into a normal body orifice)." | 2014-01-01 | ||
| 11534 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 157 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, an interview with the family nurse practitioner, and medical record review, the facility failed to notify the health care decision maker for one (1) of six (6) sampled residents after the resident's oral medications were discontinued. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the physician's orders [REDACTED]. Documentation on the physician's orders [REDACTED].#59 of the changes in the resident's medications. This was confirmed by an interview with the FNP and the resident's attending physician at 9:00 a.m. on 09/09/10. The FNP said the medications were discontinued after the FNP had a discussion with the MPOA. She said she told the MPOA she would evaluate the resident's ability to swallow and then decide if she was going to discontinue the oral medications. She said she went into the resident's room, sat the resident up in the bed, and gave the resident a drink of water. This was documented on a progress note written by the FNP on 08/19/10. The 08/19/10 progress note stated: "Chief complaint: F/U (follow-up) CXR (chest x-ray) (8/18/10) and F/U lethargy (8/18). CXR impression with New findings of subtotal collapse of right lung, possibly due to mucous plug or occult [MEDICATION NAME] lesion. "Neuro: Unchanged: lethargic, but will open eyes and speak when stimulated. "Neuro Addendum: Assessed swallowing, sat her up in bed at 90 degrees, tilted head forward, she drank 2 oz, but then coughed. "Impression: Stable chronic Problems: End stage lung CA. Terminal condition. Prognosis Poor. Suspect dysphagia and high risk for aspiration. "Plan: No change in Care Today: Called (Resident #59's MPOA) on her cell phone and updated (Resident #59's) condition. Report CXR results, VS and physical exam findings. Requested [MEDICATION NAME] give for possible 'pneumonia' Advised that [MEDICATION NAME] will probably not change outcome but will order it. (Resident #59's MPOA) stated, 'I just want her comfortable and not afraid...'" The FNP said the resident was unable to swallow, so she discontinued all of the oral medications for the resident, except for two (2) which were inadvertently missed while reviewing the medications. These were [MEDICATION NAME] and [MEDICATION NAME]. The physician's orders [REDACTED]. She also did not tell the facility's nursing staff to contact the MPOA. During an interview on 09/08/10 at 1:45 p.m., Employee #58 (a licensed practical nurse - LPN), who was present at the nursing station on 08/19/10 when the FNP spoke with Resident #59's MPOA, said she thought the FNP was going to discontinue the resident's oral medications. She said the FNP was going to evaluate the resident. Employee #58 thought the FNP told the MPOA that she was going to discontinue the medications. During an interview on 09/09/10 at 9:40 a.m., the matter of Resident #59's MPOA was not notified after the resident's oral medications were discontinued on 08/19/10 was discussed the director of nursing (DON). The DON said the first time she became aware that the MPOA had not been notified of the discontinuation of oral medications was on 08/22/10, when the attending physician did not want to restart the medications. . | 2014-01-01 | ||
| 11535 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 281 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and a review of the facility's policy regarding medication administration, the facility failed to ensure that medications were given as ordered by the physician. Resident #59 did not receive Tylenol every six (6) hours for three (3) days as ordered by the attending physician. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 "Administering Medication" policy (Revised 09/05 and 07/01/06) found Item #12 stated, "Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, "Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times." . | 2014-01-01 | ||
| 11536 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-09-09 | 514 | D | 0TPT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of facility policy, the facility failed to maintain clinical records for each resident that were complete and accurately documented in accordance with facility policy, for one (1) of six (6) sampled residents. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 "Administering Medication" policy (Revised 09/05 and 07/01/06) found Item #12 stated, "Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, "Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times." | 2014-01-01 | ||
| 11537 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-09-16 | 204 | D | WF8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to provide sufficient preparation at discharge of one (1) of six (6) sampled residents to ensure an orderly transfer from the facility, by failing to safeguard and return timely to the resident and/or responsible party important personal documents left in the facility's possession on admission which could not be produced at the time of the resident's discharge. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #94 During an interview at 3:15 p.m. on 09/13/10, Resident #96's responsible party reported she had not yet received the resident's Medicare benefits card, social security card, or her driver's license, which she had given to staff at the time of the resident's admission to the facility on [DATE]. Resident #96 was discharged from the facility on 08/20/10. The responsible party stated these identification cards were necessary for obtaining health care services for the resident. Review of the resident's closed record revealed a copy of the resident's Medicare benefits card, confirming it had been presented to the facility. There was no mention in the record of the location of the original card. During an interview with the social worker (Employee #8) at 10:40 a.m. on 09/16/10, she acknowledged the cards had not been returned and, in fact, could not be located. She stated she had met with the resident's daughter shortly before her mother's discharge and returned jewelry that had been held for the resident in the facility's safe. At that time, the daughter asked her about the cards. Employee #8 had no knowledge of the cards and had assured the daughter she would locate them and have them returned. She stated this duty had been given to the admissions clerk, who reported she had them in her possession and volunteered to return them. A week ago, the social worker had been contacted again by the resident's daughter, who had again requested the cards. When asked, the admissions clerk told Employee #8 that she had attempted to return them, and the daughter would not come to her door. The social worker stated that, on 09/10/10, she had prepared a letter to be sent to the daughter by certified mail on 09/13/10, and she produced the letter requesting the daughter to contact the facility and arrange for the return of the cards. This letter was not sent because, when the social worker arrived at the facility on Monday 09/13/10, she discovered the admissions clerk had quit on Friday 09/10/10 and could not be contacted. A search of her office failed to produce the cards. In a subsequent interview, the administrator joined the social worker. The administrator stated he was unaware the cards had not been returned, and he reported he had no knowledge of their current location. He confirmed the facility's admissions clerk had quit unexpectedly on 09/10/10. He stated it was the facility's practice for the admissions clerk to obtain the cards during the admission process, but they should be copied and returned to the responsible party. He did not know why this was not done for Resident #96. | 2014-01-01 | ||
| 11538 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-09-03 | 323 | J | LWGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home "observe / assess need for further treatment", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. On [DATE] at 11:00 a.m., the administrator, medical director, director of nursing, social worker (Employee #52), and the clinical care coordinator (Employee #33) were notified of the finding of immediate jeopardy. At 11:40 a.m. on [DATE], the administrator provided an action plan, which was reviewed and accepted by the nurse surveyor at 11:45 a.m. The action plan included the following steps: Resident #26 was transferred to a private room on another floor, staff was instructed to observe and record Resident #26's behavior on an hourly basis, and Resident #26's care plan was revised to reflect these actions. On [DATE] at 1:30 p.m., the nurse surveyor verified that Resident #26 was relocated, and the immediate jeopardy was removed with no deficient practice remaining. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following "unusual occurrence": "On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. "... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... "Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident." According to a message confirmation report, this "unusual occurrence" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, "Resident up most of the night walking around the room. Denies pain or discomfort." - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: "Res (resident) was standing behind the curtain between his bed and (Resident #38's) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right." Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, "Res stands behind curtains when your (sic) trying to give care to roommate." On [DATE], a nursing assistant wrote: "Res standing behind the curtain when giving care to roommate" Another entry (no date / time) stated, "Resident got upset when taking roommate to Bathroom (sic)." - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], "Resident behind curtain looking and trying to see the patient when staff was giving care." - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: "I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..." (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: "We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..." - 4. A QA committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: "On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... "INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: "- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. "- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. "- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. "- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. "- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. "- Resident (#26) has documented behaviors related to past roommates. ..." According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading "Patient Treatment Goals / Progress", staff at the psychiatric hospital wrote: "Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days." Under the heading "Diagnosis" was written: "Axis I: Dementia, AD (Alzheimer's disease) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..." Under the heading "Discharge Recommendations / Plan" was written: "NH to observe and assess for further treatment." An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's "Resident Transfer" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: "Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party." "Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs." This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: "On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own." - The second note stated: "Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. "On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. "At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. "After that is when we found (Resident #77) with the pillow on his face. "That's (sic) when I initiated the 20 minute check paper for the CNA to fill out." (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, "[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified" and "fell last noc (night). Be sure he is in middle of bed." For Resident #77, staff recorded "Lethargic". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, "Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night." For Resident #77, staff recorded, "Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI." For Resident #26, staff recorded, "Restless up in room several X's throughout night." - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician's progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, "CNA reported as she came up the hall (sic) resident had a pillow across his face. ..." At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), " ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..." - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: "Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, psychosis diagnosis, hx (history) of episodes of agitation." G: "Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date." (The revised review date for this goal was [DATE].) I: "Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation." The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: "Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]." The goal for this problem statement was: "Resident will continue to have not episodes of socially inappropriate behavior weekly by review date." (The revised review date for this goal was [DATE].) The interventions included: "... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..." The care plan did not describe what these "socially inappropriate behaviors" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to "observe / assess for further treatment" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: "To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). "Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff." - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.) - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: "Precautions related to (Resident #26)". In the body of the memorandum was: "(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. "Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this." The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - "Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]." G - "Resident will have less than weekly episodes of socially inappropriate behaviors by review date." G - "Resident will have no episodes of attempting harm other residents through review date." Interventions included: "Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered." . | 2014-01-01 | ||
| 11539 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-09-03 | 520 | J | LWGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home "observe / assess need for further treatment", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following "unusual occurrence": "On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. " ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... "Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident." According to a message confirmation report, this "unusual occurrence" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, "Resident up most of the night walking around the room. Denies pain or discomfort." - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: "Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right." Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, "Res stands behind curtains when your (sic) trying to give care to roommate." On [DATE], a nursing assistant wrote: "Res standing behind the curtain when giving care to roommate" Another entry (no date / time) stated, "Resident got upset when taking roommate to Bathroom (sic)." - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], "Resident behind curtain looking and trying to see the patient when staff was giving care." - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: "I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..." (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: "We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..." - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: "On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... "INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: "- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. "- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. "- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. "- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. "- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. "- Resident (#26) has documented behaviors related to past roommates. ..." According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading "Patient Treatment Goals / Progress", staff at the psychiatric hospital wrote: "Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days." Under the heading "Diagnosis" was written: "Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..." Under the heading "Discharge Recommendations / Plan" was written: "NH to observe and assess for further treatment." An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's "Resident Transfer" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: "Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party." "Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs." This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: "On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own." - The second note stated: "Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. "On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. "At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. "After that is when we found (Resident #77) with the pillow on his face. "That's (sic) when I initiated the 20 minute check paper for the CNA to fill out." (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, "[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified" and "fell last noc (night). Be sure he is in middle of bed." For Resident #77, staff recorded "Lethargic". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, "Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night." For Resident #77, staff recorded, "Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI." For Resident #26, staff recorded, "Restless up in room several X's throughout night." - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, "CNA reported as she came up the hall (sic) resident had a pillow across his face. ..." At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), " ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..." - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: "Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation." G: "Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date." (The revised review date for this goal was [DATE].) I: "Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation." The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: "Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]." The goal for this problem statement was: "Resident will continue to have not episodes of socially inappropriate behavior weekly by review date." (The revised review date for this goal was [DATE].) The interventions included: " ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..." The care plan did not describe what these "socially inappropriate behaviors" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to "observe / assess for further treatment" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: "To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). "Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff." - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: "Precautions related to (Resident #26)". In the body of the memorandum was: "(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. "Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this." The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - "Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]." G - "Resident will have less than weekly episodes of socially inappropriate behaviors by review date." G - "Resident will have no episodes of attempting harm other residents through review date." Interventions included: "Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered." - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. | 2014-01-01 | ||
| 11463 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 224 | D | H9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to obtain approval from the Social Security Administration before it, while serving as an organizational representative payee, reimbursed Summersville Memorial Hospital for medical debts in arrears for one (1) of twenty-three (23) Stage II residents. Resident identifier: #28. Facility census: 49. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to Summersville Memorial Hospital's skilled nursing unit on [DATE], and expired at the facility on [DATE]. Review of the resident trust fund accounting information revealed the facility paid a total of $733.01 to Summersville Memorial Hospital from Resident #28's personal fund account maintained by the facility on [DATE], [DATE], and [DATE], for services incurred at Summersville Memorial Hospital on [DATE], [DATE], [DATE], [DATE], and [DATE] - all of which were debts made prior to her admission to the skilled nursing unit. During a telephone interview with the resident's former medical power of attorney representative (MPOA) and spouse on [DATE] at approximately 8:00 p.m., they spoke their belief that the facility should have forwarded any extra money the resident had in her personal account to the resident's burial fund rather than paying bills that were five (5), six (6), and seven (7) years old and which incurred when she resided in the acute care portion of the facility. During an interview with the staff member responsible for patient accounts (Employee #130) on [DATE] at 9:30 a.m., she said the skilled nursing unit is a subdivision of Summersville Memorial Hospital, and their tax identification numbers are the same. She handles accounts for the skilled nursing unit and explained that Resident #28's old debts to Summersville Memorial Hospital had been turned over to a collection agency. She said she assumed that, if a resident had a previous bill from any hospital or other bill (such as an unpaid electric bill), the facility managing the funds would pay outstanding debts presented. She produced evidence the Social Security Administration (SSA) designated Summersville Memorial Hospital to serve as Resident #28's organizational representative payee on [DATE]. On page 3 of the Advance Notification of Representative Payment form from the SSA dated [DATE], the facility answered "no" to question #11, when it asked if the claimant (Resident #28) was "indebted to your institution for past care and maintenance". Employee #130 stated that, at that time, the skilled nursing unit was unaware of the past due debts owed to Summersville Memorial Hospital; it was not until the bad debts were turned over to a collection agency and the past due bills were presented to the facility for payment on [DATE], [DATE], and [DATE] (totaling $733.01) that the staff at the skilled nursing unit became aware of the debt. When asked if the facility had requested permission from the SSA to pay those outstanding debts to Summersville Memorial Hospital before making the payments, Employee #130 said they had not, and she was not aware that they needed to obtain this permission, since they were the resident's representative payee. . | 2014-02-01 | ||
| 11464 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 257 | C | H9I611 | . Based on the results of the complaint investigation (State Complaint Reference # ), it was determined the facility failed to maintain a comfortable building temperature of at least 71 degrees Fahrenheit (F). Facility census: 51. Findings include: a) The National Weather Service (NOAA: www.weather.gov/climate/) temperature archives indicate the outside temperature in the greater Beckley area, beginning on 09/26/10 and continuing through 10/04/10 - a nine (9) day period, was no greater than 69 degrees F. The daily low temperature during this time period was no greater than 58 degrees F. The lowest daily temperature during this time period was 38 degrees F. on 10/02/10. When questioned as to when the facility heating system became functional, the facility's administrator stated an attempt to activate the heating system had failed on 10/01/10 due to a faulty valve. The valve and the heating system became functional on 10/04/10. Without a functional heating system, it would not be possible to maintain the building temperature at a minimum of 71 degrees F during this time period. . | 2014-02-01 | ||
| 11465 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 241 | D | SHO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview and staff interview, the facility staff failed to treat residents with respect. Staff walked past Resident #71 who was requesting assistance without acknowledging her presence or her request. When interviewed, Resident #71 (who was alert and oriented) reported staff members frequently did not identify themselves to her when giving her care. The resident said she felt like staff treated her like a child. This was observed to be true for one (1) of four (4) sampled residents. Resident identifier: #71. Facility census: 118. Findings include: a) Resident #71 At the initial unannounced entrance to the facility on [DATE] at 3:30 p.m., Resident #71 was observed standing in the doorway of her room waving a water pitcher in the air and saying in a loud voice, "I need some water. Will you get me some water?" As she was making this request, staff members were observed to walk past her and not pay attention to her. A nurse was down the hall passing medications, and two (2) nursing assistants walked past her without saying anything. Resident #71, when interviewed at 4:10 p.m. on 10/17/10, stated she had tried to get the staff to help her several times, but "some of them just run from you." When asked if she knew the names of the staff members that she has difficulty getting help from, she stated, "No, because they do not tell you their name and probably don't want you to know it." She then named several staff members who did treat her respectfully and stated, "They were wonderful and very nice, but some of them just run from you and ignore you." The resident stated, "I do not appreciate being treated like I am a child." This surveyor turned on the call light in Resident #71's room at 4:15 p.m. on 10/17/10. The call light was promptly answered at 4:16 p.m. A nursing assistant (Employee #56) came in the room and asked, "What do you need?" while walking past this resident and looking at the roommate. Resident #71 told this nursing assistant, "I have been trying to get you to help me, and you would not even stop and see what I wanted." The nursing assistant responded, "You caught me in a run." The nursing assistant was asked by this surveyor what her name was, because she wore no name tag, and she was identified herself. The resident stated she did not know this employee's name, because "The staff here never tell you their names, but she is one of the ones who ignored me earlier." Employee #56 proceeded to assist the resident's roommate (Resident #24) to the bathroom. Another staff member then came in, and Employee #56 told her that she needed to go to the bathroom. Resident #71 then asked, "Who is assigned to this room?" Employee #56 told her the name of her assigned caregiver. Resident #71 stated she did not know who that was. She then stated, "I know their names if they tell me," and she again named staff members by name and said, "They treat you wonderful, but some don't even tell you their name." Medical record review revealed Resident #71 was alert / oriented and had capacity to understand and make her own informed health care decisions. She lived alone and came to the facility following a knee replacement. She did not have any long-term or short-term memory problems and was independent with cognitive skills for daily decision-making. The social worker (Employee #53) was notified of the above observations at 10:30 a.m. on 10/18/10. At 11:00 a.m., this surveyor accompanied this social worker to interview Resident #71. The resident described to the social worker the incident that had occurred the day before, and the social worker initiated an investigation into the incident at that time. . | 2014-02-01 | ||
| 11466 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 242 | D | SHO311 | . Based on observation, confidential family interview, and staff interview, the facility did not always honor residents' food likes and dislikes. Resident #78 was served beets for dinner, even though this was specifically listed on her tray card as one (1) of the two (2) food items this resident did not like. This was identified during one (1) random meal observation on 10/17/10. Facility census: 118. Findings include: a) Resident #78 During initial tour of the facility on 10/17/10 at 3:40 p.m., interviews were conducted with family members and alert / oriented residents. In one (10 confidential interview, a family member who visited frequently reported the facility staff did not honor residents' food preferences, stating, When you tell them you do not like something, you seem to get it anyway." This family member did report that staff will obtain substitute food items upon request. During an observation on 10/17/10 at 6:00 p.m., a test tray was requested to replace the last tray served on the hall (to check the temperature of food items at the time of service). This tray was intended for Resident #78. The temperature of food items on the tray were within an acceptable temperature range. Observation found the meal served to Resident #78 consisted of Swedish meatballs, pasta, beets, peaches, and milk. Review of Resident #78's tray card, which lay beside the plate on her tray, disclosed two (2) items listed under "dislikes" - beets and green beans. According to assessment information provided by the facility, Resident #78 was not able to participate in an interview due to cognitive impairment. Her food was pureed, and she was fed by staff. She would not have been able to request a substitute for the beets. The dietary manager, who was present at the time of this observation at 6:00 p.m. on 10/17/10, verified that beets were listed as a dislike on this resident's tray card. A new tray was requested for this resident following the testing of her tray. . | 2014-02-01 | ||
| 11467 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 356 | C | SHO311 | . Based on observation and staff interview, the facility failed to post - accurately and at the beginning of each shift - the required information to identify the staff members providing care and the census of the facility. Observation, on 10/17/10 at 3:40 p.m., found the posted nurse staffing information was dated 10/16/10, and the census information was absent. This practice has the potential to affect all residents and visitors. Facility census: 118 Findings include: a) Observation of the facility's posted nursing staffing data, on 10/17/10 at 3:40 p.m., found the posting was dated 10/16/10. The only nursing staffing data recorded on this posting was for the day shift of 10/16/10, and there was no resident census information recorded as required. An interview with the charge nurse (Employee #49), on 10/17/10 at 3:40 p.m., confirmed this information had not been updated to reflect the numbers of nursing staff or residents currently in the building. | 2014-02-01 | ||
| 11468 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-10-19 | 280 | D | SHO311 | . Based on observation, staff interview, and medical record review, the facility failed to revise the nutrition care plan and Kardex used by nursing assistants caring for Resident #50 to accurately reflect the services to be furnished to the resident following a significant change in the resident's status, after she received a fracture to the right arm and became totally dependent on staff for eating. This was true for one (1) of four (4) sampled residents. Resident identifier: #50. Facility census: 118. Findings include: a) Resident #50 Observation of the evening meal, on 10/17/10 at 6:00 p.m., found Resident #50 being fed by a family member. Resident #50's right arm was in a sling, and she was not moving her arm. A second observation of this resident, in the dining room during the noon meal on 10/18/10, found her being fed by a nursing assistant; the resident was totally dependent on staff for eating and drinking. She was not initiating any movement of her right arm to participate in the task of eating. In an interview with the nursing assistant providing care to Resident #50 (Employee #26) on 10/19/10 at 10:00 a.m., Employee #26 was questioned about the amount of assistance Resident #50 required with meals. Employee #26 stated the resident could not move her right arm and she required total assistance with meals. Review of Resident #50's medical record disclosed a significant change in status minimum data set (MDS) was completed on 09/27/10. According to this assessment, the resident was totally dependent on one (1) staff member for eating. Review of her current care plan found the resident's nutrition plan was not reviewed or revised following her change in condition. The interventions listed for maintaining the resident's weight still stated, "Assist resident with meals to extent needed." It was not specific to the amount of staff assistance she needed with eating. This approach was written on 04/27/10, and was reviewed on 07/16/10, but it was not revised after the resident's significant change assessment on 09/27/10. Further review of the care plan found Resident #50's self-care deficit plan was revised on 09/28/10, to state she required total assistance from one (1) staff member with locomotion, eating, bathing, and personal hygiene. When questioned on 10/19/10 at 10:00 a.m. about how staff knows how much assistance a resident needs according to her/his care plan, Employee #26 said there was an ADL (activity of daily living) sheet that describes each resident's needs. The ADL sheet (Kardex) for Resident #50, when reviewed, found the resident was identified as being "independent with set-up help only" with eating. There was no evidence Resident #50's Kardex (the means by which the facility communicated elements of the care plan to direct care staff for each resident) had been updated to reflect a significant change in the resident's self-feeding ability. | 2014-02-01 | ||
| 11469 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-10-07 | 318 | D | UP4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of four (4) sampled residents, who had limited range of motion (ROM) of the left hand, received appropriate treatment and services to prevent further decrease in ROM. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 Review of the resident's medical record did not find any evidence that a brace was supposed to be put on the resident. Observations made on 10/06/10, during the day at 9:00 a.m., 12:00 p.m. and 2:00 p.m., did not find evidence of a brace on the resident's left hand and wrist. On 10/07/10, a brace was found on the resident's left hand at 10:25 a.m., and the nursing assistant (NA - Employee #17) was in the room providing care for the resident, when interviewed, stated he did not care for the resident on a regular basis and did not know about the splint. A licensed practical nurse (LPN - Employee #132) who provided care for the resident, when interviewed at 10:30 a.m. on 10/07/10, said she thought therapy was supposed to get the resident a new brace, but she was not sure if it had been ordered yet. At 11:00 a.m. on 10/07/10, the interim director of nursing (DON) reported the resident was "on the therapy board" but, due to issues with payment, therapy was only doing evaluations for her. Interview with the assessment nurse, on 10/07/10 at 1:30 p.m., found the resident did not have a care plan for a splint, as there was no physician's order for one. Interview the rehab program director (Employee #105), at 1:45 p.m. on 10/07/10, found she did not start here until July 2010 and did not know about any issues regarding this resident. Employee #105 later said the rehab program was going to pick up the resident again and try to do some therapy for her. At 2:10 p.m. on 10/07/10, the occupational therapist (OT - Employee #162) said a new brace with finger separators would be ordered for the resident, and she would set up a splinting schedule with training for the resident's family and staff. She also reported she performed a new evaluation of the resident on 10/07/10, compared it to an OT evaluation that was completed on 05/06/10, and found the resident had not lost any ROM in that hand. A review of the resident's comprehensive annual assessment, with an assessment reference date (ARD) of 05/12/10, found in Section G the resident had limited ROM of one (1) hand with full loss of voluntary movement. In Section S, the assessor noted the resident's left hand had a contracture. Review of the resident assessment protocol (RAP) for activities of daily living / functional rehabilitation potential, dated 05/19/10, found it did not address the resident's contracture. Review of the resident's current care plan, with a created date of 03/19/10, confirmed the interdisciplinary team identified the resident was at risk for loss of ROM "r/t (related) to existing contractures of her left hand and ankle, but the care plan did not include an intervention to apply a splinting device to the resident's left hand. Review of the OT Evaluation, with a signature date of 05/11/10, noted, "... Pt is @ (arrow pointing up) risk for contractures & presenting /c (with) (arrow pointing down) PROM (passive range of motion) in (L) UE (left upper extremity) (symbol for 'secondary to') [MEDICAL CONDITION]/[MEDICAL CONDITION] Dx ([DIAGNOSES REDACTED]. Pt would benefit from skilled OT services for contracture Mgt (management) programs (illegible) splinting, positioning & staff education for (L) UE." found the resident to have 0-70 degree ROM in the left wrist and she was at high risk of developing a contracture due to a [DIAGNOSES REDACTED]. A request was made of Employee #105, on the afternoon of 10/07/10, for any other information about the resident's therapy plan; Employee #105 reported the only information she had was on the resident's medical record. Review of the resident's medical record found a form titled "Rehabilitation Screening", dated 04/01/10, with an entry by Physical Therapy which stated; "Pt (patient) not appropriate for contracture management program due to poor rehab potential for functional outcome." Review of an OT Rehabilitation Summary, dated 06/08/10, noted the resident was being discontinued from OT, stating, "Pt participated in all tx (therapy) sessions and has met all LTG's (long-term goals) @ this time. Pt is currently utilizing a resting hand splint on (L) hand to assist /c positioning (in order to (arrow pointing down) risk of further contracture). ..." The author of this entry further noted staff and family were educated on the resident's splint schedule, and the resident was to receive passive ROM before having the splint applied. Review of the 10/07/10 OT Evaluation found the long-term goal for the resident was: "Pt to tolerate WHO (wrist-hand orthotic) /c out complaints of skin irritation / breakdown to prevent further deformity and management of (L) UE contractures." Treatment approaches included: "Splint Evaluation, Splint training, and Contracture management." | 2014-02-01 | ||
| 11470 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-10-07 | 312 | D | UP4G11 | . Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure staff provided necessary assistance to maintain good grooming and personal hygiene for (1) of four (4) sampled residents who was unable to do so for herself. Resident #134 did not always receive mouth care, which she was unable to do for herself. The resident expressed that she would like to get out of bed for short periods of time but was not able to get out of bed by herself and was not gotten up by staff. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 1. Observations made with a licensed practical nurse (LPN - Employee #132) and a nursing assistant (NA - Employee #17), on 10/07/10 at 10:30 a.m., found the resident's teeth had food debris on them. The resident, when interviewed, reported she had not received mouth care that day or on other days on a regular basis. She stated she had her own teeth and said she had to ask staff to clean her teeth, in order to get them taken care of. The NA reported he cleaned her teeth whenever she asked him to. The resident was observed again with the interim director of nursing (DON) at 11:00 a.m. on 10/07/10. Review of the resident's care plan, dated 06/22/09, found the resident was to be assisted with oral care as needed. - 2. Observation of the resident, on 10/06/10 at 9:00 a.m., 12:00 p.m., and 2:00 p.m. and on 10/07/10 at 10:30 a.m., found the resident in bed. When interviewed on 10/07/10 at 11:00 a.m., Resident #134 reported she would like to get up, but when she did, she often was left up too long (several hours) in the geri chair and it became uncomfortable for her. She said she would be willing to get out of bed for one (1) hour at a time, if staff would put her back to bed in a timely manner. The interim DON was present for this interview. Employee #132 (LPN), when interviewed on 10/07/01 at 10:30 a.m. during an earlier observation of the resident, reported the resident would get up for showers, to get her hair done, and to get her bed made. Review of the care plan, dated 06/02/09, found the resident would be encouraged assisted to change positions frequently and transferred with a mechanical lift using a two (2) person assist. The activities care plan note, dated 08/12/10, stated, "Resident requires max assist w/ (with) activity intervention d/t (due to) impaired mobility. Her participation has decreased this review period due to episodes of not feeling well... Resident will attend large group activities... Her husband visits daily and stays for extended periods, as well as visits from her daughter. No sign change." . | 2014-02-01 | ||
| 11471 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-04 | 166 | D | PYV111 | . Based on a review of the resident council minutes, medical record review, resident interview, family interview, and staff interview, the facility did not ensure all complaints made by residents, families, or responsible parties were documented and investigated. In addition, the facility did not follow up with those individuals making the complaints, to let them know the outcome of the complaint investigation and the resolution to the issue. Resident identifier: #66. Facility census: 120. Findings include: a) Resident #66 During tour of the facility on 10/03/10, a family interview revealed Resident #66 had experienced some problems with having to sit in a soiled brief for a long period of time. The resident had wanted to attend a church service but had to wait for a long time before she could go, because staff was not available to change her soiled brief. On 10/04/10 at approximately 9:00 a.m., telephone contact with Resident #66's family revealed this incident took place in September 2010. The family member indicated there were problems with getting assistance from nurse aides on the last two (2) Sundays in September. The family member reported nurse aides told her they could not assist in changing Resident #66's brief until the lunch trays were picked up. The family member related that, on 09/19/10, she had complained to staff but did not put her complaint in writing. On 09/26/10, she did write a letter listing her concerns about staff not assisting Resident #66 with incontinence care. The family member put the letter under the administrator's door. The administrator confirmed this did occur and that he passed the letter along to Employee #50, the unit manager on the hall where Resident #66 lives. In an interview on 10/04/10 at approximately 11:00 a.m., Employee #50 (registered nurse unit manager) confirmed she had received this letter from the administrator. She said she investigated the family's concerns. The outcome of the investigation did reveal a nurse aide had told the family member she could not assist in changing Resident #66's brief until she finished picking up lunch trays. Employee #50 could not remember the name of this particular nurse aide. She did say she had instructed this individual to always assist a resident if they needed something done, even if they were in the process of picking up trays. Employee #50 did not have any documentation about this incident. There was no evidence of any education that had taken place with the nurse aide involved. Also, there was no evidence that the facility had contacted the family member to let them know the outcome of the investigation. On 10/04/10 at approximately 12:00 p.m., Resident #66 said she did have to wait for long periods of time on occasion to get her brief changed. She said, recently, the wait time had been reduced to twenty (20) minutes. The administrator agreed this resident needed to know what had occurred in regards to the investigation about her concerns with her brief not changed timely. He confirmed that, up to this point, that had not taken place. On 10/04/10 at approximately 12:45 p.m., review of the resident council minutes from 09/21/10 revealed the council members expressed concerns regarding call lights not being answered timely on Cherry hall. The activity director (Employee #80) indicated she had not passed this information from the council along to the unit manager of Cherry hall. The administrator agreed this information needed to passed along in a timely manner and that it had not occurred. | 2014-02-01 | ||
| 11472 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-21 | 253 | D | 6HW411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, family interview, and staff interview, the facility failed to clean the floor adequately for one (1) of eight (8) sampled residents. Numerous observations of the resident's floor found it to be sticky, even after having been recently mopped. This stickiness had the potential to affect the steadiness of the gait of the resident who was known to ambulate within the room independently; it also compromised safety of others, as it had the potential to harbor bacteria that could be transmitted throughout the facility on the soles of shoes of all staff who entered the room. Resident identifier: #61. Facility census: 120. Findings include: a) Resident #61 Record review revealed Resident #61's [DIAGNOSES REDACTED]. During interview with the nurse unit manager (Employee #51) on 10/19/10 at 4:30 p.m., she said Resident #61's physician orders [REDACTED]. Resident #61 experienced a fall in early October, but x-rays completed af the emergency room ruled out any new fractures; she was wearing hipsters at the time of the fall. Currently, she was on the waiting list for inpatient care at a behavioral health / medicine center related to problem behaviors that were not able to successfully be redirected. Observation of the resident throughout the survey found she walked in her room independently, ambulated to the toilet independently, and was observed closing the door to the hallway on more than one (1) occasion. Observation of the resident's floor, on 10/18/10 at 3:00 p.m., revealed the floor was sticky in a wide area around all sides of the bed. The sticky floor was also observed by the life-safety code (LSC) surveyor who brought it to the attention of Employee #133 (the environmental service director), who immediately called staff to mop the floor. Observation, on 10/18/10 at 5:30 p.m., found the floor had dried and was just as sticky as it had been previously. Observation of the floor, on 10/19/10 at 9:00 a.m., found the floor to be sticky all around the bed. This was called to the attention of the LSC surveyor, who again notified the environmental service director, who again called staff to mop the floor. After drying, the floor remained sticky in places. During an interview on 10/19/10 at approximately 11:00 a.m., Employee #133 said numerous members of the housekeeping staff had been out of medical leave in recent times, which had cut down their daily number of traditional full-time housekeeping staff on duty. Observation of the floor in Resident #61's room, on 10/20/10 at 9:05 a.m., found the floor to be sticky in one (1) small area, but this was an improvement over observations made on the preceding two (2) days. Review of recent resident / family grievances found one dated 09/30/10, related to the sanitation of Resident #51's room. During a telephone interview with this family member on 10/18/10 at 7:00 p.m., she acknowledged the room had been cleaned the week of her request, but she had issues with the cleanliness of the room during the following week, as it related to allegedly finding mouse droppings on the floor on 10/07/10. She said she found Resident #51's floor sticky on the left side of the bed where staff sat while feeding him. Review of recent resident / family grievances found one dated 09/22/10 from Resident #27, who complained his room was not cleaned even when housekeeping staff was asked by the resident to do so. This grievance was followed up by the facility. Review of the resolution portion of the grievance found a note that, on 10/03/10, housekeeping again did not clean his room. Review of recent resident / family grievances found one dated 09/23/10, where Resident #117's family member complained the resident's room was "filthy ... mopped but not swept". Facility's resolution included having the room deep cleaned 10/05/10, with follow-up contact with the family. Review of the 09/21/10 Resident Council meeting minutes found three (3) residents (names not identified) complained of housekeeping staff not cleaning their room adequately. During an interview with the administrator on 10/19/10 at approximately 10:00 a.m., he said the facility, in recent weeks, had adopted a different mopping product for a trial on a couple halls which included the 200 hall where Resident #61 resided. When informed of the persistent stickiness of the floor in Resident #61's room even after mopping, he said it was probably time to complete an evaluation of the product change. . | 2014-02-01 | ||
| 11473 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-21 | 309 | D | 6HW411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to monitor the effectiveness of treatment after administration of Tylenol for a new development of fever and in the presence of other symptoms and complaints; the facility also failed to monitor the temperature of a dependent resident with a history of repeated urinary tract infections after a new onset of fever early in the morning. This was evident for one (1) of six (6) sampled residents. Resident identifier: #51. Facility census: 120. Findings include: a) Resident #51 During an interview via telephone on 10/18/10, Resident #51's family member stated that, on 01/10/10 Resident #51 developed a high fever and was medicated with a fever-reducing medication, and five (5) hours elapsed before his temperature was re-checked by staff. By this time, he was totally unresponsive and the fever had elevated even more. Subsequently, he was transported to the hospital for a twelve (12) day stay. Upon his return to the facility, the pressure ulcer on his coccyx had worsened to a Stage IV wound, and he required a wound VAC after the area was surgically debrided during the hospitalization . Medical record review revealed Resident #51's temperature was 100.9 degrees Fahrenheit (F) on 01/10/10 at 3:30 p.m., and he was medicated with [MEDICATION NAME]. The physician was notified, and new orders were received for a urinalysis and culture to be obtained the following day. Further medical record review revealed that, at 5:30 p.m. on 01/01/10, he refused dinner and complained of not feeling well. The nurse documented his refusal to go to the emergency room . There was no evidence that his temperature was monitored at this time, to ascertain whether the [MEDICATION NAME] was effective in reducing his temperature, and there was not evidence to reflect the family was notified of the fever. It was not until 8:00 p.m. on 01/01/10 that the nurse again assessed him again; she documented his temperature had risen to 104.7 degrees F and he was "non-responsive" and had no "appropriate pain response". He was medicated with Tylenol per standing order for fever and was transferred to the emergency room at 8:30 p.m., where he was admitted and subsequently spent the following twelve (12) days. During an interview with the interim director of nursing (DON) on 10/19/10 at approximately 4:00 p.m., she said there was no policy regarding reassessing a resident's temperature after he/she was identified as having a new onset of fever; rather, it was left to the nurse's discretion. Per request, the DON and a medical records staff member (Employee #50) said they would try to locate and copy any documentation that could be found in addition to the nursing notes for 01/10/10 which gave evidence of temperature assessments within that five (5) hour time frame. However, none was produced. Observation, on 10/20/10 at 9:00 a.m., found Resident #51 was not in the facility. Staff interview found he was sent to the emergency room this morning around 8:00 a.m. Record review, on 10/21/10, revealed a nursing note dated 10/19/10 at 5:57 a.m., documenting the resident had a temperature at 101.4 degrees F and was medicated with Tylenol 650 mg every "4 hours PRN (as needed) up to 3 doses. If temp (temperature) persists call MD (medical doctor)." Record review revealed his temperature was checked once again at 9:00 a.m. on 10/19/10 and was afebrile at 98.5 degrees. Further record review revealed no evidence that his temperature was assessed again until the following morning, twenty-one (21) hours later, on 10/20/10 at 6:12 a.m., when it was found to be 103.1 degrees F. He was medicated with Tylenol, and the physician was paged. At 8:10 a.m. on 10/20/10, the nurse recorded the resident "remains confused & lethargic. Temp. 102.1", and orders had been received to send him to the emergency room for evaluation and treatment. Record review found he was transferred to the emergency room at 8:28 a.m., and returned to the facility on [DATE] at 12:59 a.m., with a [DIAGNOSES REDACTED]. During an interview with the nurse unit manager (Employee #51) on 10/21/10 at 10:00 a.m., she was unable to produce evidence that this resident's temperature had been assessed with [REDACTED]. She stated the nurse from day shift yesterday (10/19/10) may have forgotten to record a temperature assessment, as well as the 7:00 p.m. to 7:00 a.m. She also said the new onset of fever for Resident #51 had not been noted on a 24-hour shift report. | 2014-02-01 | ||
| 11474 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 328 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure one (1) of ten (10) sampled residents received the maximum benefit of each aerosolized treatment ordered by her physician. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's order permitting her to self-administer the aerosolized treatments; however, there was no evidence the interdisciplinary team completed an assessment to ensure the resident was capable of reliably self-administering these treatments, and this self-administration of aerosolized medications was not addressed on her care plan. Licensed nursing staff was aware Resident #111 did not self-administer these treatments in an effective manner, and they did not provide additional monitoring / supervision to ensure she received the maximum benefit of each treatment. Additionally, licensed nursing staff did not complete pre- and post-treatment assessments that would allow them to determine whether the treatments were effective. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's order, dated 11/23/10, stated, "Res (resident) may administer [MEDICATION NAME] / Atrovent treatments herself." An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's minimum data set assessment (MDS) history, beginning with an MDS dated [DATE] and continuing through the most recent MDS dated [DATE], revealed the resident was identified as being unable to self-medicate. Review of the resident's medical record failed to find evidence the resident was assessed for the ability to self-medicate. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as "Exhibiting or is at risk for complications related to [MEDICAL CONDITION]", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's order was written to permit this on 11/23/10. -- 4. The resident, when interviewed again on 12/06/10 at 4:15 p.m., reported she did not receive her 5:00 a.m. nebulizer treatment either. She said that, when the nurse set up the nebulizer, she was smoking and when she returned from smoking, most of the medication in the cup to the nebulizer had drained from the cup. She tried to utilize the medication remaining in the cup and it was not effective. She stated that, when this happens, she becomes short of breath. -- 5. A subsequent interview with Employee #21, on 12/06/10 at 4:30 p.m., found the resident's next scheduled nebulizer treatment was due at 5:00 p.m., but she would wait until 5:45 p.m. before administering the next treatment. This would only allow two (2) hours and forty five (45) minutes between treatments. Employee #21, when asked if the nurse on the night shift had reported to her that Resident #111 did not receive an effective treatment at 5:00 a.m., responded that she did not. The nurse reported that she marks the treatment as given on the MAR indicated [REDACTED]. The nurse stated she did not assess the resident's heart rate, respiratory rate, and breath sounds prior to initiating a treatment and after each treatment was finished. -- 6. Review of the facility's policy titled "2.12 Medications: Self Administration" (effective 06/01/96 and revised 01/01/04) revealed the following, "Process: "1. When a customer requests medication self administration, initiate the process to assess customer's capability. The customer must meet the follow criteria. "1.1. Be able to demonstrate: "1.1.1. Knowledge of medications and medication schedule "1.1.2. Self-administration including use of packaging, reading label, open containers; and "1.1.3. Ability to administer medications properly, e.g., insulin / syringe, eye drops, inhalers as needed. "2. If assessment indicates customer is capable of medication self-administration, notify physician to obtain order. "3. Address medication self-administration in customer's care plan. Include plan for: "3.1. Storage, location of medications, and documentation of medication administration; "3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and "3.3. Ongoing monitoring and reassessing of customer's capacity. "4. Securing medications at the nursing station. Keep a limited quantity in a locked drawer at customer's bedside. Assure that customer and nursing both have a key. "5. Instruct customer in medication self-administration procedure. Include: "5.1. Obtaining medication "5.2. Administering medication according to physician order; "5.3. Recording administration on documentation record. "6. Monitor customer to assure medication is administered as ordered and for effectiveness and/or side effects of medication. "6.1. Notify physician of any side effects of changes in condition that may require medication adjustment. "6.2. Notify physician and care plan team if customer demonstrates decrease in capability for medication self-administration. "7. Adjust plan for medication self-administration as indicated. "8. Document: "8.1. Customer's request and assessment of capability in Nurses' Notes or progress notes; "8.2. Plan for storage, location, documentation, education, and monitoring on customer's care plan; "8.3. Ongoing monitoring of customer's capability in Nurses' Notes." -- 7. Review of the "Assessment for Self-Administration of Medications" (dated 1992), found the following instructions: "Before performing this assessment, verify that there is a physician order in the resident's chart for self-administration of the specific medication under consideration and that the resident has signed the appropriate document stating the desire to self-administer his/her own medication. Proceed by checking the appropriate response below for each of the 19 items listed. The resident must be able to perform each step indicated below prior to beginning self-administration of medications. The interdisciplinary team will be responsible for approving self-medication using the assessment as a guide." Item #19 of the assessment asked, "Can administer inhalant medication with proper procedure?" -- 8. Review of the resident's MAR found the form used for documenting self-administration of medications titled "Self Medication Administration Record" was not utilized. -- 9. Review of the facility policy titled "11.21 Small Volume Nebulizer" (dated 01/01/04 and revised 06/01/04), revealed at Item #8, before a nurse administered medications utilizing a nebulizer, the nurse was supposed to: "Assess the patient's heart rate, respiratory rate, and breath sound prior to initiating treatment." Item #20 stated, "Upon completion of the treatment, check patient's heart rate, respiratory rate, and breath sounds." -- 10. On 12/07/10 at 10:00 a.m., the interim director of nursing was interviewed and additional information was requested. As of exit on 12/09/10 at 12:00 p.m., no additional information was provided with respect to the above concerns. . | 2014-02-01 | ||
| 11475 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 280 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed, for one (1) of ten (10) sampled residents, to revise the resident's care plan to address her self-administration of aerosolized medications after an order was received from her physician to permit this. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's orders [REDACTED]." An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as "Exhibiting or is at risk for complications related to [MEDICAL CONDITION]", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's orders [REDACTED]. -- 4. Review of the facility's policy titled "2.12 Medications: Self Administration" (effective 06/01/96 and revised 01/01/04) revealed the following under the heading "Process": "3. Address medication self-administration in customer's care plan. Include plan for: "3.1. Storage, location of medications, and documentation of medication administration; "3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and "3.3. Ongoing monitoring and reassessing of customer's capacity. . | 2014-02-01 | ||
| 11476 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2010-10-14 | 164 | E | S21C11 | . Based on observation, staff interview, and a confidential resident group interview, the facility failed to ensure resident privacy was maintained during showers. The men's and women's shower rooms shared a common whirlpool area, and the privacy curtains separating these areas could not be pulled closed to ensure privacy during bathing. This had the potential to affect any resident showered in the central shower rooms at the facility. Facility census: 56. Findings include: a) During a tour of the facility on 10/13/10 at 2:00 p.m., the men's and women's shower rooms were visited by two (2) health facility surveyors. The doors to the shower rooms were separate, but once inside the shower rooms, the men's and women's rooms were connected via a common whirlpool area with full visual access from either side. There were tracks for two (2) sets of privacy curtains, one (1) on either side of the whirl pool area. The only side that had privacy curtains was located on the women's side, and one (1) of the surveyors was unable to pull closed the privacy curtains on this side. The privacy curtains were observed with the facility's administrator at 2:05 p.m. with both surveyors present. The administrator reported that men and women were not showered at the same time. Two (2) nursing assistants (Employees #7 and #54), whom the administrator indicated were shower aides for that day, were interviewed. They indicated they showered about thirty (30) residents on that particular day and finished before noon. They said they did not shower men and women at the same time. During a resident group interview on 10/14/10 at approximately 3:00 p.m., two (2) of four (4) female residents in the group reported they were given showers within the past week while men were in the common shower area at the same time. They reported the privacy curtains could not be pulled all the way closed in order to prevent others from observing while they are taking a shower. They also reported they were able to see the male residents in the shower. This was confirmed during a second observation by one (1) of the health facility surveyors just after the group interview. | 2014-02-01 | ||
| 11477 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-10-14 | 280 | D | LTYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to address adjustment issues this resident faced. Resident #28 had [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 0.5 mg twice a day for anxiety / agitation. He also received [MEDICATION NAME] 50 mg once a day for depression, as well as Mirtazepine ([MEDICATION NAME])[MEDICATION NAME](orally disintegrating tablets) 15 mg once a day at bedtime for depression. The care plan addressed specifics as to how the facility would monitor the resident's behavior to protect and ensure the safety of others. However, it failed to address the resident's relocation to a new environment and associated adjustment difficulties, especially in view of his pre-existing [DIAGNOSES REDACTED]. On 10/13/10, medical record review for Resident #28 revealed nursing staff had observed the resident talking to himself in his room on or near 09/29/10. The staff member identified this as a new behavior. Another staff member overheard the resident threatening to harm an incapacitated resident on 09/27/10. On 10/14/10 at approximately 4:00 p.m., the administrator and director of nursing confirmed the facility's interdisciplinary team had not addressed in the care plan how the move would impact the resident's psychosocial well-being. They agreed this was a significant life-changing event for someone with dementia, anxiety, and depression. They also agreed the care plan should have revised with goals, and interventions to assist the resident in reaching the goals, to promote the resident's highest practicable level of well-being. | 2014-02-01 | ||
| 11478 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2010-10-06 | 285 | D | 4XPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the WV Medicaid program manual for nursing facilities, the facility failed to coordinate their assessments with the preadmission screening and resident review (PASRR) program under Medicaid as required. The facility readmitted a resident from an inpatient psychiatric stay prior to receiving approval by the State-designated reviewing agency - West Virginia Medical Institute (WVMI), which resulted in the resident having no payer source to cover his continued stay at the facility when it was determined by WVMI that he was no longer medical eligible for nursing home placement under WV Medicaid criteria. Resident identifier: #56. Facility census: 112. Findings include: a) Resident #56 Record review revealed Resident #56 came to the facility on [DATE] with a pre-admission screening form (PAS-2000) signed by the physician on 01/18/10, who indicated his primary [DIAGNOSES REDACTED]. This PAS-2000 was reviewed by WVMI on 01/20/10, at which time the reviewer determined Resident #56 was medically eligible, under the WV Medicaid criteria, for nursing facility services and that a Level II evaluation was necessary. A Level II evaluator determined Resident #56 did not require specialized services for mental illness or mental [MEDICAL CONDITION] on 01/22/10. Resident #56's initial PAS-2000 indicated he was appropriate for nursing home placement for a period of up to six (6) months, after which another PAS-2000 would have to be completed for his nursing home stay to continue to be paid for by WV Medicaid. During this six-month period, Resident #56 was admitted for inpatient psychiatric services from 05/28/10 until 06/09/10, when he was readmitted to the nursing home. A second PAS-2000, signed by a physician on 06/15/10, indicated Resident #56 needed nursing home services and was not likely to eventually return home. On 06/17/10, a reviewer from WVMI denied the request for nursing home admission for Resident #56, stating he was "ineligible for long-term care (nursing home) admission based upon WV Medicaid criteria." This determination was made after Resident #56 had already been readmitted to the nursing facility, which resulted in the resident having no payer source to pay for his continued stay in the nursing home. In an interview on 10/06/10 at approximately 2:30 p.m., the social worker (Employee #1), director of nursing (Employee #2), and administrator (Employee #3) all indicated they did not know the resident needed an approved PAS-2000 prior to his readmission at the facility from an inpatient psychiatric stay. The nursing facility manual, Chapter 514 Section - 514.8.2 states: "To qualify medically for the nursing facility Medicaid benefit, an individual must need direct nursing care twenty-four (24) hours a day, seven (7) days a week. The Bureau has designated a tool known as the Pre-Admission Screening form (PAS) to be utilized for physician certification of the medical needs of individuals applying for Medicaid benefit .... "Each nursing facility must have an original pre-admission screening tool to qualify the individual for Medicaid and to meet the federal PASRR requirements. Should the receiving nursing facility fail to obtain an approved assessment prior to admission of a Medicaid eligible individual, the Medicaid program cannot pay for services. The individual cannot be charged for the cost of care during this non-covered period. "A Medicaid recipient who converts from Medicare Part A coverage to Medicaid does not need a new assessment to receive the Medicaid benefit. Medicaid coverage can be reinstated as long as a Medicaid denial letter has been issued. "A new medical assessment must be done for Medicaid eligibility for the nursing facility resident for all of the following situations: "- Application for the Medicaid nursing facility benefit; "- Transfer from one nursing facility to another; "- Previous resident returning from any setting other than an acute care hospital; "- Resident transferred to an acute care hospital, then to a distinct skilled nursing unit, and then returns to the original nursing facility; and "- Resident converts from private pay to Medicaid." As Resident #56 was returning from a setting other than an acute care hospital, a new PAS-2000 was required prior to his re-admission to the nursing facility. | 2014-02-01 | ||
| 11479 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 278 | B | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at 1:05 p.m., confirmed the resident was not on a toileting plan but was checked regularly for bladder incontinence. d) Resident #81 Review (on 01/06/09) of the quarterly MDS, completed on 11/23/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at about 1:00 p.m., confirmed the resident was not on a toileting plan. . | 2014-02-01 | ||
| 11480 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 279 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: "Refer to the physical restraint / enabler assessment." 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, "Refer to the physical restraint / enabler assessment." The goal associated with this problem was "(Resident) will be free of negative effects with the use of an enabler." This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which, when reviewed, did not refer to the lap buddy in any way); refer to the falls assessment prevention and management plan of care (which did not include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy): prevention and management plan of care; maintain resident bowel and bladder routine; educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was incomplete). The care plan for this resident's lap buddy use did not specify the problem necessitating the application of the device. Additionally, record review revealed the resident became agitated and had sustained injuries when the device was applied, and this response was not addressed in the resident's care plan. b) Resident #10 Review of the interdisciplinary care plan for Resident #10, found a fifty (50) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan stated, "Recent or chronic history of incontinence. Contributing factors included laxative use PRN and cognitive / perceptual impairment, loss of sphincter control, and decreased physical activity." One (1) goal for problem statement was: "Will ingest adequate fluids evidenced by resident's skin turgor." Other goals were: "Will have bowel movement every three days" and "Will be cooperative with assisted toileting." The interventions to assist with achievement of these goals included, "See nutritional care plan" and "See skin integrity prevention and management plan of care." The stated interventions did not address the identified problem and would not lead to achievement of the established goals. c) Resident #97 1. Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her "pain medications are scheduled". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, "Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). " Another note, dated 01/01/09 at 4:35 a.m., stated, "Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time." A nursing note, dated 01/01/09 at 1:35 p.m., stated, "Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor." There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with "an alteration in comfort related to pain secondary to L (left) shoulder pain." Pre-printed goals were checked for this problem statement as follows: "Decrease persistent pain to a tolerated level so resident can function in daily life"; "Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and "Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity." Also included were the following functional goals: "Participate in ADL's"; "Participate in therapies"; "Will not experience decline in functioning related to pain"; and "Non-pharmacological measures will be used as alternatives to medication when appropriate." The interventions for achieving the goals written above were as follows: "Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN." This care plan was not individualized to address Resident #97's pain. 2. The resident's care plan also contained the following problem statement: "Refer to the physical restraint / enabler assessment." The goal stated: "Will be free of negative effects with the use of an enabler." (There was no mention about how the enabling device was intended to improve the resident's functionality.) One (1) intervention simply stated what device was to be used (1/2 top side rail) to aid in turning and reposition. The only other intervention was "Refer to the mood and behavior symptom plan of care." Review of the mood and behavior plan of care found no interventions related to the use of an enabler. There were no interventions written to assist in achieving the goal established. 3. The director of nursing (DON - Employee #2) was made aware of the inconsistencies in Resident #97's care plan at 10:00 a.m. on 01/08/09. She stated she was aware there were a lot of pages in the care plan, but this was the way their corporation required them to do the care plans. She was made aware that the resident's true problems often could not be identified and the treatment they were to receiving often did not match the care plans. d) Resident #28 Medical record review, on 01/06/09 at 1:32 p.m., revealed Resident #28 was on several medications for moods / behaviors, including [MEDICATION NAME] 12.5 mg via g tube BID (two-times-a-day), [MEDICATION NAME] 0.5 mg via g tube TID (three-times-a-day), and [MEDICATION NAME] 10 mg via g tube QD (every day). Review of the resident's most current care plan, dated 11/26/08, found the facility identified the resident was at risk for depression as evidence by "unhappy behavior symptoms" and persistent anger with self or others. The goal included reduction / elimination of unhappy behavior symptoms. Interventions to achieve the goal included: "offer time to express feelings and concerns; separate from stressful situations; 1:1 (one on one) conversation to maintain trust of staff; offer reassurance; and depression scale q3 (every three) months." Another problem was behavioral symptoms that may be harmful to self or others or interfere with function or care as evidence by yells out loud and grabs, combative with staff. The goal included no injury to self or others. Interventions included: "administer medications, see nsg (nursing) mar (medication administration record), redirect to activity of 1:1 diversion, offer time to express feelings and concerns, separate from stressful situations, redirect to act. or 1:1 act (activity or one-on-one activity) offer to call son." Review of the resident's minimum data set assessment (MDS), dated [DATE], revealed Resident #28 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited repetitive verbalizations, repetitive anxious complaints, sad pained worried facial expressions crying and tearfulness (of which all were easily altered). Review of the behavior tracking report, from 06/01/08 through 11/30/08, found the following: - 06/17/08 - crying and "mood persistence" (each one time). - 07/27/08 - crying - 08/08/08 - crying and "mood persistence" - 08/21/08 and 08/30/08 - crying - 09/02/08 and 09/03/08 - physical abuse (a behavior which was not described) - 10/03/08 - crying - 10/04/08 - crying and "mood persistence" - 10/06/08 - sad / pained / worried facial expression and "mood persistence" - 10/07/08 - crying two (2) times and "mood persistence" - 10/26/08 - crying and repetitive verbal, unrealistic fears, repetitive anxious, sad / pained / worried facial expression, and "mood persistence" - 10/27/08 - crying and "mood persistence" - 11/15/08, 11/21/08, and 11/25/08 - crying and "mood persistence" The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. e) Resident #62 Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several medications for moods / behaviors. Her physician's orders [REDACTED]. - On 10/31/07 - [MEDICATION NAME] tablets 20 mg PO (by mouth) Q AM (every morning) and [MEDICATION NAME] 50 mg po BID; - On 02/20/08 - [MEDICATION NAME] 200 mg PO QD and [MEDICATION NAME] 100 mg PO QD; - On 05/15/08 - [MEDICATION NAME] 5 mg po BID; - On 11/12/08 - [MEDICATION NAME] 0.25 mg PO Q AM, [MEDICATION NAME] 0.5 mg PO Q HS (every night), and [MEDICATION NAME] ER 250 mg PO QD. Review of resident's current care plan, last updated on 10/15/08, revealed the interdisciplinary care team identified Resident #62 exhibited behavioral symptoms that may be harmful to self and/or others or that interfered with function or care, as evidenced by "cognitive deficit Alzheimer's, doesn't understand the need to be here." The goals associated with this problem statement were no injury to self or others and to reduce the frequency of behavioral symptoms. Interventions included: "1:1 conservation to calm, reminisce, see act poc (see activity plan of care), offer to call family." Another problem statement addressed: "Socially inappropriate - yells out loud for nurses to help her. Yells that she's sick or has to go to the bathroom; anxious / repetitive questions, statements." The goal associated with this problem statement was: "Will exhibit socially appropriate behaviors." Intervention included: "offer reassurance, encourage rest encourage activities, separate from stressful situations, offer to call son, take for a walk." Review of the resident's most recent MDS, dated [DATE], revealed Resident #62 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited negative statements, repetitive questions, repetitive verbalizations, unrealistic fears, recurrent statements that something terrible was about to happen, repetitive anxious complaints, [MEDICAL CONDITION], sad / pained / worried facial expressions, crying / tearfulness, and repetitive movements (all of which were not easily altered). Additionally, the assessor identified that the resident exhibited wandering, verbally abusive, physical abusive, and socially inappropriate behaviors and resists care (all of which were not easily altered). Review of the behavior tracking report, from 09/11/08 through 10/10/08, revealed she exhibited behaviors on only four (4) days during the two-month period (09/30/08, 10/06/08, 10/07/08, and 10/10/08). The behaviors being tracked were: negative statements, repetitive questions, repetitive verbal, persistent anger, self deprecation, unrealistic fears, terrible things to happen, repetitive health, unpleasant mood, [MEDICAL CONDITION], sad / pained / worried facial expression, crying, repetitive physical, mood persistence, wandering, wandering altercation, verbal abuse, verbal altercation, physical abuse, physical altercation, socially inappropriate, social altercations, and resists care. Specific examples of these behaviors (such as what constituted "mood persistence") were not identified in either the resident's assessments, care plan, or behavior tracking report. The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. f) Resident # 81 Medical record review (on 01/06/09) of the physical restraint / enabler plan of care, dated 09/24/08, revealed the following problem statement: "Refer to the physical restraint / enabler assessment." The associated goal was: "Will be free of negative effects with the use of the enabler". The plan did not identify the reason for use of the enabler and did not establish a goal based on the assessment and the use of the enabler. . | 2014-02-01 | ||
| 11481 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 309 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an "as needed" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her "pain medications are scheduled". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, "Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). " Another note, dated 01/01/09 at 4:35 a.m., stated, "Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time." A nursing note, dated 01/01/09 at 1:35 p.m., stated, "Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor." There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. A review of the physician orders [REDACTED]. The resident also had a PRN order for [MEDICATION NAME]. There was no evidence in Resident #97 that staff offered the [MEDICATION NAME] for breakthrough pain between the scheduled doses of [MEDICATION NAME]. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with "an alteration in comfort related to pain secondary to L (left) shoulder pain." Pre-printed goals were checked for this problem statement as follows: "Decrease persistent pain to a tolerated level so resident can function in daily life"; "Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and "Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity." Also included were the following functional goals: "Participate in ADL's"; "Participate in therapies"; "Will not experience decline in functioning related to pain"; and "Non-pharmacological measures will be used as alternatives to medication when appropriate." The interventions for achieving the goals written above were as follows: "Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN." This care plan was not individualized, and the stated interventions were not initiated when the resident expressed that her routine pain medication was not effective. The nurse did not offer her the PRN [MEDICATION NAME] for breakthrough pain, and there was no evidence that, when the resident expressed continued pain between the routine doses of [MEDICATION NAME], the nurse assessed the pain (type, location, severity, etc.) and provided alternate interventions. The director of nursing (DON - Employee #2) was notified, on 01/07/09 at 6:30 p.m., of the episodes of pain which were not thoroughly assessed and treated by the nurse. The DON agreed the nurse did not intervene according to the standards of practice when the resident expressed the need for additional pain medication. b) Resident #10 1. The physician' s orders, dated 01/01/09, contained an entry for: "0.45% NS (normal saline) infuse at 75cc/hr PRN if not eating / drinking." Medical record review revealed the resident was not eating, and she was receiving comfort care. The family did not desire a feeding tube, but they did want the IV fluids for hydration. This resident was observed on 01/05/09 at 2:30 p.m. with IV fluids infusing into her right hand. Another observation, at 6:00 p.m. on 01/06/09, found two (2) different nursing assistants attempting to feed this resident. She would not eat, spitting the food out and turning her head. She also was not drinking. The IV fluids were infusing at 75cc/hour at that time. Review of the medical record revealed staff was not accurately recording the amounts of fluid received by the resident on a daily basis. This IV fluid was ordered "as needed" and not continuously, and there was no record of accurate intake of these fluids per shift. There was no intake and output (I&O) record in the medical record on 01/01/09 or 01/05/09. It could not be determined, from the medical record, how much fluid intake this resident. Additionally, the resident's fluid output was not recorded on the I&O worksheets. This resident had an indwelling Foley urinary catheter, which would facilitate the measurement of the resident's urinary output. However, the urinary output was not recorded, and there was no evidence that anyone had compared the resident's output to the intake to check for a fluid balance. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR, there was no documentation to reflect IV fluids were administered on 01/06/09, and there was no intake records found for that day; however, this surveyor observed IV fluids being administered on 01/06/09 at a rate of 75cc/hour. During an interview with the minimum data set assessment (MDS) nurse (Employee #23) at 10:45 a.m. on 01/07/09, on she was asked if fluid I&Os were recorded elsewhere. She was unable to locate any further records of fluid I&O, and she verified there was no evidence the resident's fluid balance was being adequately monitored. 2. Resident #10 also had contractures to both hands. The resident's most current plan, updated on 11/25/08, specified as an intervention: "Rolled up washcloths in left hand at all times." The care plan also stated, "Place resting splint on right hand from 9:00 a.m. to 3:30 p.m."; staff was to place a rolled up washcloth in her right hand after the splint was removed. On multiple occasions on 01/05/09, 01/06/09, 01/07/09, and 01/08/09, observation found nothing in this resident's hands to prevent further contractures. On two (2) different occasions, the resident was wearing socks over her hands, but there were no devices in place to address the resident's contractures. During an interview with the MDS nurse at 10:45 a.m. on 01/07/09, she stated this resident should have had something for positioning in her hands due to the contractures. c) Resident #40 1. Medical record review, observation, and staff interview (on 01/06/09 and 01/07/09) revealed Resident #40 did not have on the "double Geri gloves at all times" as ordered by her physician. Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found the geri gloves were above her wrist and were not the double gloves. 2. The resident also had a physician's orders [REDACTED].@ all times". Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found both heels were resting directly on the beds. . | 2014-02-01 | ||
| 11482 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 371 | F | UFEY11 | Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. . | 2014-02-01 | ||
| 11483 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 441 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing. After the incontinence brief was removed and the resident was cleansed, the nursing assistant used her contaminated gloved hands to pull up the resident's covers and pull back the privacy curtain between the two (2) beds. During interview with the director of nursing (DON - Employee #2) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as "standard" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). b) Resident #65 During record review on 01/06/09, the record revealed Resident #65 had a urinalysis laboratory report showing a UTI, reported on 11/06/08. This urinalysis / urine culture report identified E. coli as the infecting organism. The record contained another urinalysis laboratory report showing a UTI, reported on 10/25/08. This urinalysis / urine culture report identified Citrobacter freundii as the infecting organism. On 01/07/09, review of the infection control report / log for November 2008 did not show this resident's name, the presence of a UTI, or the cultures infectious. Review of the October 2008 infection control report / log, on 01/07/09, revealed this resident's name and "UTI"; however, the infecting organism was not noted. On 01/07/09 at 6:30 p.m., the DON (who was also the infection control nurse) was made aware of these findings. No additional documentation was provided. c) Resident #75 Record review, on 01/07/09, revealed Resident #75 was seen at the emergency department at a local hospital on [DATE] - 12/19/08. The "Hospital to Extended Care Facility Transfer Information" form (dated 12/19/08) recorded a [DIAGNOSES REDACTED]. The facility subsequently obtained the laboratory report and provided copy to the surveyor on 01/08/09. This urine culture laboratory report identified Proteus mirabilis as the infecting organism. On 01/08/09, review of the infection control report / log for December 2008 revealed this resident's name with "URI" (upper respiratory infection) listed. The log did not show the resident's UTI or the infecting organism. d) Resident #35 Record review for Resident #35 revealed a urinalysis (UA) done on 12/19/08. The laboratory results indicated this resident had a UTI with E. coli present. This resident's UTI was treated, but there was no evidence the facility had monitored the infection and investigated the reason for this infection. This type of infection is often caused by inadequate perineal care. There was no evidence that the facility placed this resident on the facility's infection tracking form for tracking or trending. e) Resident #97 During an interview on 01/06/09, this resident stated, "I have urinary tract infections a lot, and I am careful how I wash." The resident then explained that she does not like the facility staff to give her a bath or wash her, because "they do not know how to do it right to keep you from getting an infection." She said, "When I came in here, one of the nursing assistants gave me a shower and washed me back to front, and I will not let them wash me anymore." The resident stated she "reported this to the desk" and now they let her take a bath herself. --- Part II -- Based on random observations, the facility failed to ensure staff distributed ice water in a manner to prevent the potential development and transmission of disease and infection. This was evident for all the residents on the 300 Hall and 400 Hall who were allowed to have water pitchers at the bedside. Facility census: 113. a) First observation 01/05/09 at 3:00 p.m., and shortly thereafter on the 300 Hall, a nursing assistant was observed during ice pass holding water pitchers directly over the open ice chest while dipping ice into the residents' used water pitchers, a practice which could potentially transmit microorganisms from the exterior surface of the dirty pitcher to the clean ice which was served to the residents on that hall. The nursing assistant was observed filling two (2) pitchers from room [ROOM NUMBER], one (1) pitcher from room [ROOM NUMBER], and two (2) pitchers from room [ROOM NUMBER] in this manner. At 3:15 p.m., the above observations were reported to the nurse (Employee #27), who immediately spoke with the nursing assistant about the matter. On the 400 Hall, three (3) nursing assistants were observed during ice pass dipping ice into residents' used water pitchers directly over the open ice chest below. At 3:20 p.m., 3:21 p.m., and 3:22 p.m., three (3) nursing assistants were each observed filling two (2) pitchers at a time in this manner, and one (1) single pitcher filled at 3:25 p.m. At 3:26 p.m., this practice was relayed to the corporate nurse (Employee #100), as she also observed one (1) of the three (3) nursing assistants dipping ice into two (2) pitchers directly over the ice chest, and she immediately addressed the situation with that nursing assistant. The corporate nurse then relayed information regarding this practice of dispensing ice to the administrator (Employee #1). b) Second ice pass observation During an observation of medication administration on 01/06/09 at 9:10 a.m., a nursing assistant (Employee #58) was observed passing ice to the residents on the 400 hall. Employee #58 was observed to enter room [ROOM NUMBER] and remove two (2) ice pitchers. The nursing assistant held the ice pitchers over the ice chest and filled them with ice. Following the previous day's observations and management interventions, staff continued to pass ice in a manner which could lead to the spread of microorganisms. . | 2014-02-01 | ||
| 11484 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 328 | E | UFEY11 | Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: "Label nasal cannula (also humidifier) with resident name, date, and liter flow." Review of Section 2.2.1. General Requirements found, under the procedure for the subject of Disposable Equipment Change Schedule subset 1.n.: "02 (Oxygen) delivery devices - for example Venturi masks, nasal cannulas, oxygen supply tubings - every 5 days and PRN (as needed)." When asked on 01/06/09 approximately 2:30 p.m., the director of nursing (DON - Employee #2) said the facility's policy was to change nasal cannulas and tubings weekly. On 01/07/09 at approximately 6:30 p.m., the above findings were reported to the DON. . | 2014-02-01 | ||
| 11485 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 164 | E | UFEY11 | Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the shower experience lacked privacy, she said she can see the breasts of residents in the adjoining shower while she is being showered. When asked about the blocks that extended part of the way up the shower stalls on each side facing the other stall, she replied she could see the residents' breasts over the blocks, as they were not high enough to block the view. When asked about the shower curtain between the stalls, she replied she had not ever noticed if there was a shower curtain between the stalls. She clarified she also saw the "bottoms" of other residents when they were brought out of the shower stall naked. When asked if there was a curtain between the showers and the main door, she replied in the affirmative but stated, for example, when she was brought in for a shower and was waiting her turn to get in, she could see the bodies of other residents around the curtains, as the curtains were not pulled fully closed and/or gapped open. e) The above findings were reported to the director of nursing (DON - Employee #2) at approximately 6:30 p.m. on 01/07/09. She stated she was not aware of these findings in the facility. . | 2014-02-01 | ||
| 11486 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 221 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as "enablers" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan directing staff to apply "socks to hands at all times". The medical symptom for the use of this physical restraint was "prevent scratching face, removal of O2 (oxygen)". This care plan then said, "D/C (discontinue) 12/19/2008." During an interview with the minimum data set assessment (MDS) nurse (Employee #23) on 01/07/08 at 10:45 a.m., the MDS nurse verified that the intervention to put socks on Resident #10's hands was discontinued on 12/19/08, and restraints should not have been in use on the days this surveyor observed the socks on this resident's hands on 01/05/09 and 01/06/09. b) Resident #36 Review of Resident #36's medical record found a physician's order, dated 12/05/08, stating, "Resident may have standard size lap buddy to be used to protect resident from injury to herself or others as a therapeutic enabler to maintain the resident's highest physical & mental well being. Will re-evaluate prn (as needed), not to exceed 90 days. Will monitor use of this enabler @ least q (every) 30 minutes & release, assess & provide needs q2hr / prn (every two hours as needed). Resident may be enabler free during meal time while supervised. Use of this enabler is secondary to unsteady gait secondary to dementia." Further review of the medical record revealed that, on 12/05/08, a "Physical Restraint / Enabler Assessment" was completed. Documentation on this assessment stated the conditions and circumstances necessitating the use of the restraint were "danger of harming self or others", as well as "to improve self functioning" through promoting "proper positioning". Instructions on the section titled "Restraining Device" stated "complete if device is a restraint to be used to enhance functioning"; this section was left blank, even though the section above stated the device was being used "to improve self function". The next section on the assessment was titled "Enabler Device", which was to be completed if the device were an enabler to enhance functionality. The assessor recorded "poor safety awareness with frequent falls" as the medical symptom to be treated by the use of the device. The assessor also recorded that the device was to be used when the resident was in the wheelchair. Another form in the medical record titled "Physical Restraint / Enabler Information" was reviewed. There was a separate form for various devices used for this resident. These forms described if the device was a physical restraint or an enabler and the potential benefits and risks. (A separate form was completed for the perimeter mattress, the mobility alarm to the bed, the mobility alarm to the wheelchair, the low bed, and the lap buddy.) The form completed for the lap buddy identified was the device as an enabler of which this resident was cognitively aware. Among the benefits for using this device, the assessor recorded reduce risk of falls and maintenance of proper body positioning. The form contained a section titled "Potential risks of a physical restraint / enabler use may include:"; this section was left blank. Further review of the nursing notes and incident / accident reports revealed this resident did not want the lap buddy attached to her chair, and it caused increased agitation. An incident / accident report, dated 12/05/08 at 7:00 a.m., stated, "Resident continually tries to get out of chair to bed or from bed to chair. Resident placed in chair, belt alarm on and checked, resident taken to area beside nurses station. Lap Buddy put on and seat belt alarm removed." An incident / accident report, dated 12/06/08 at 7:00 a.m., stated, "Res (resident) was pushing at lap buddy while CNA (certified nursing assistant) was trying to put it on her wheelchair and residents wrist band slid and cut her arm." Further documentation on this report recorded the resident "stated that she was mad over lap buddy and was trying to keep the CNA from putting it on the WC (wheelchair)". Another incident / accident report, dated 12/11/08 at 11:30 a.m., stated, "Res (resident) did not want lap buddy put back on after going to the restroom. She pushed on lap buddy, fighting against the CNA and she got a skin tear on R (right) forearm." Documentation on this incident / accident report indicated the resident was not compliant with the use of the prescribed assistive device and she tried to remove the lap buddy. An incident / accident report, dated 12/21/08 at 10:00 a.m., stated Resident #36 "reopened a ST (skin tear) to the L (left) arm. Resident was fighting against CNA who was putting lap buddy on WC. She was flailing her arms around and hit arm on wheelchair." A nursing note, dated 12/21/08 at 4:30 p.m., recorded, "Resident continues to kick and hit during the application of lap buddy. Will monitor use of new lap buddy." A nursing note, dated 12/25/08 at 1:00 p.m., recorded, "Resident loud and verbal this a.m. (morning) Has made several attempts at removing lap buddy from chair, becomes physically aggressive with staff during care. Continue to monitor." A nursing note, dated 01/03/08 at 6:30 p.m., recorded, "Res observed throwing water pitcher full of water onto floor of room. She had also pushed over the bedside table. Resident stated that she wanted her lap buddy removed. Will continue to monitor for adverse behavior." An interdisciplinary progress note, dated 12/15/08, recorded a new medication was being used and stated, "She is also not always compliant with wearing double geri-gloves. She will take the off and not let the staff place them." There was nothing mentioned about the noncompliance with the lap buddy or the fact that this resident was resistant to its use and was injuring herself with this device, which was ordered for safety to prevent injury. The resident's physical restraint / enabler care plan, dated 12/05/08, did not contain a problem, goal, or interventions with respect to the use of the lap buddy to promote increased functioning; the care plan simply said, in the first section, "Refer to the physical restraint / enabler assessment"; the associated goal was: "Will be free of negative effects with the use of an enabler." The interventions listed did not assist in achievement of the stated goal. The interventions were: apply the enabler (lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which was reviewed and did not refer to the lap buddy in any way or resisting its use); refer to the falls assessment prevention and management plan of care (which did include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy) prevention and management plan of care; maintain resident bowel and bladder routine; and educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was not complete). The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning, nor did it address the fact that the resident became agitated / resisted using this device and sustained injuries when the device was applied. During a dinner observation at 6:00 p.m. on 01/06/09 and a lunch observation at 12:30 p.m. on 01/07/09, this resident was observed sitting in her room eating independently with the lap buddy still attached to her wheelchair. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she stated this device was not a physical restraint; it was an enabler. When questioned about the difference between a physical restraint and an enabler, she indicated that, if a resident could not get up own his/her own, it was not a restraint. She was made aware of the inconsistent documentation and the inadequate assessment of this device for Resident #36. c) Resident #35 Record review revealed the following physician's order dated 12/19/08: "Lap buddy may be used to protect resident to maintain residents highest physical / mental well being. Will reevaluate prn (as needed) not to exceed 90 days. Will monitor use of this restraint at least 30 minutes and release q 2 hours prn to assess and provide needs as needed. May be restraint free during meal time while supervised. Use secondary to dementia." Further record review revealed a form titled "Physical Restraint / Enabler Information", dated 12/19/08, on which was written "Lap Buddy". Documentation on the form indicated the lap buddy was an enabler and the resident could remove it at will. The record contained another form titled "Physical Restraint / Enabler Assessment. Documentation on this assessment form stated that the conditions for restraint consideration for this resident included "danger of harming self or others". Documentation at the bottom of the form indicated the device was an enabler to enhance functionality. According to this information, the enabler device was being used to treat the following medical symptom: "Unable to ambulate independently secondary to [MEDICAL CONDITION]". Review of the resident's current care plan, dated 12/05/08, found the statement: "Refer to the physical restraint / enabler assessment." The goal associated with this statement was: "Will be free of negative effects with the use of an enabler." The interventions were not pertinent to assist with the achievement of this goal. The interventions simply stated: "Apply enabler, lap buddy, to wheelchair. Medical symptom: poor safety awareness secondary to dementia and [MEDICAL CONDITION]. Review the physical restraint / enabler sheet every 90 days." The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning. The DON, when interviewed about the use of this lap buddy, verified that the use / purpose of this device was inconsistently documented, and she acknowledged it was ordered by the physician as a physical restraint but was treated by the facility as an enabler. d) Resident #28 Medical record review, conducted on 01/06/09 at 1:32 p.m., revealed Resident #28 had physician's orders for a pommel cushion and a lap buddy. Further review revealed both devices were identified as "enablers" to protect her from injury due to decreased safety awareness. Review of the facility document titled "Physical Restraint / Enabler Information" found the following difference between a physical restraint and an enabler: - "A physical restraint is any manual or physical or mechanical device, material or equipment attached or adjacent to the resident body that cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body." - "An enabler is a device, material or a piece of equipment attached or adjacent to the residents' body that the resident can easily remove and is cognitively aware of." The Centers for Medicare & Medicaid Services (CMS) state, "Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body." On 01/06/09 at 5:30 p.m., the licensed practical nurse (LPN - Employee #36) identified that Resident #28 was not able to remove her lap buddy. Review of the resident's quarterly minimum data set assessment (MDS), dated [DATE], identified the resident's cognitive skills for daily decision making were moderately impaired. The use of the lap buddy with pommel cushion with Resident #28, therefore, did not meet the facility's own definition of an "enabler". Review of the facility policy titled "5.2.1 Physical Restraint / Enabler Program" revision date April 2006 identifies on page, in section 3-C: "Select appropriate physical restraint alternative / enabler based on assessment. - Complete Restraining Device Section, if the device is a restraint used to enhance functionality. - Complete Enabler Device Section, if the device is an enabler used to enhance functionality." Review of the document titled "Physical Restraint / Enabler Assessment" for the lap buddy (initially completed on 11/28/07 updated on 02/03/08, 05/14/08, and 11/19/08) found the assessor never identified the lap buddy as a physical restraint. Review of the resident's current care plan, dated 11/26/08, found staff identified the lap buddy as an enabler, although the device met the facility's definition of a physical restraint (not an enabler). The care plan did not contain a systematic and gradual plan towards reducing the use of the restraint (e.g., gradually increasing the time for ambulation and muscle strengthening activities), nor did the care plan identify what care and services would be provided during the periods of time when the restraint would be released or what meaningful activities would be provided. e) Resident #85 Record review revealed Resident #85 used a lap buddy daily, but there was no systematic plan for restraint reduction, release, and meaningful activities to be provided. There was also a discrepancy within the facility's documentation as to whether her lap buddy was a physical restraint or enabler. Documentation on the physical restraint information sheet, dated 4/15/08, noted the application of a lap buddy to her wheelchair and defined a physical restraint as a device that "cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body". The assessor consistently documented in Section P4 of the resident's MDS assessments, dated 06/26/08, 09/25/08, and 12/2508, that a "trunk restraint" was in use. During an interview on 01/08/09 at 11:15 a.m., Employee #18 said the MDS assessments were coded incorrectly, and the lap buddy should have been coded as a chair preventing rising, and agreed they should have one (1) care plan per device. Review of Resident #85's current care plan found the use of a physical restraint was initially developed on 04/15/08. The care plan did not specify interventions of a systematic plan for restraint reduction nor for planned releases of the lap buddy. The care plan also did not specify meaningful activities, rather it stated to "See Activity Pursuit POC" (plan of care). Review of the activity pursuit plan of care found interventions of large music groups, socials, parties, and visits with family, but there were no plans to offer diversional activities as a part of a restraint reduction plan to keep the resident engaged, so that a physical restraint may not be necessary. Interview with the activities director (Employee #11), on 01/08/09 at 2:00 p.m., revealed her belief that Resident #85 had declined a lot the past few months and no longer took part in many activities; she estimated the resident's attention span to be ten (10) minutes at the most. She said she did provide for Resident #85 one-on-one activities two (2) or three (3) times per week. She cited the resident's illness in September as the beginning of her decline and produced an activity record for August that evidenced much more participation in activities. Random observation on 01/07/09, between 11:15 a.m. and 11:30 a.m., found her up in the wheelchair with the lap buddy in place. During this time, she entered four (4) residents' rooms. Housekeeping staff brought her out once, a nursing assistant brought her out once, and she left on her own accord twice. Another random observation on 01/07/09, between 11:33 a.m. and 11:41 a.m., revealed she was up in the wheelchair with the lap buddy in place. Her daughter came in for a visit to feed her and to walk around the building with her, and she continued to have the lap buddy in place throughout the family visit until the daughter left at 1:30 p.m. She was returned to bed at 1:45 p.m. after being in the wheelchair with the lap buddy for at least two and one-half (2-1/2) hours. On 01/07/09 at 6:15 p.m., the DON stated a "restraint is anything that restricts you from standing up", citing if a resident could not stand up voluntarily anyway, then the device was an enabler (not a physical restraint). She stated that, if a resident were leaning or scooting out of a chair, then the lap buddy would also be an enabler; she replied in the affirmative when asked if a tied restraint would also be an enabler in that same situation. She said she believed an enabler was coded as a trunk restraint on the MDS. . | 2014-02-01 | ||
| 11487 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 285 | D | UFEY11 | Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. . | 2014-02-01 | ||
| 11488 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 329 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation to reflect an assessment for [MEDICATION NAME] or extrinsic factors that may have caused or contributed to the increase in behaviors. On 10/01/08, she again exhibited increased behaviors, and she was given [MEDICATION NAME] 1 mg IM. The facility did not contact the psychiatrist regarding these events. A urinalysis later revealed Resident #62 had a urinary tract infection [MEDICAL CONDITION]. The facility failed to rule out [MEDICATION NAME] or extrinsic causes of the increased behaviors prior medicating her with [MEDICATION NAME] IM. 4. On 11/12/08, the attending physician added [MEDICATION NAME] ER to the resident's medication regimen. There was no evidence to reflect the facility contacted the psychiatrist regarding changes in the resident's behaviors / condition for which the attending physician added the [MEDICATION NAME] ER. 5. On 01/07/09 at 4:15 p.m., the director of nursing (DON - Employee #2) was questioned if psychiatric services was consulted upon increase in behaviors. On 01/08/09, the DON was unable to provide any information to show that the facility had contacted the resident's psychiatrist after any of the episodes which resulted in changes in her psychoactive medications. . | 2014-02-01 | ||
| 11489 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 520 | E | UFEY11 | Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as "standard" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). There was no evidence that the facility's QAA committee had been monitoring the effectiveness of the facility's infection control program. (See also citation at F441.) Quality deficiencies would have been evident had the QAA committee members reviewed the facility's infection incidence rate reports and/or infection surveillance worksheets, which were incomplete. . | 2014-02-01 | ||
| 11490 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 225 | D | UFEY11 | Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, "the aids (sic) hurt her legs and were rough with her". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There was also no evidence that this bruising of unknown origin was investigated or reported to the appropriate state agency. During an interview at 12 noon on 01/08/09, the DON stated she did not report the injuries. During an interview at 12:10 p.m. on 01/08/09, the administrator stated she would check into these injuries. She subsequently confirmed there was no accident / incident report and the injuries were not been reported to the State agencies. There was no formal investigation initiated to find the cause of the injuries. A "late entry" accident / incident report was shown to the surveyor at 1:30 p.m. on 01/08/09. . | 2014-02-01 | ||
| 11491 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 313 | D | UFEY11 | Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to "see all the time". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, "I don't hear well." After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, "Resident noted to refuse to interact with staff members for brief period, ignored this nurse when asked to take medications. VS (vital signs) were WNL (within normal limits)." The nurse then indicated that, when the nursing assistant addressed the resident, the resident responded cooperatively. During medical record review, the resident's hearing was reviewed. The admission assessment, dated 04/08/08, indicated the resident had hearing aids. The minimum data set (MDS) assessment indicated the resident did not have problems understanding others when a a hearing device was used. The care plan identified the resident was hard of hearing and contained an intervention - "hearing aid clean" . The care plan did not direct the caregiver to be sure the resident wore the hearing aids when she was up and/or to be sure that the hearing aids were working properly. A nursing assistant (Employee #63) was observed providing care for this resident at 12:30 p.m. on 01/08/09. She was asked if she had provided care to this resident in the past, and she said she had been here a while and had worked with this resident many times. When asked if she was aware the resident had hearing aids, she stated she was not aware of this and she had not seen them. At that time, Resident #36's roommate, from behind the privacy curtain, said, "She has them in her drawer at her bedside." The nursing assistant looked in the drawer and found two (2) hearing aids in a small case. The nursing assistant tried them and said that they must need batteries, because they were not working. The facility did not assure this resident's assistive hearing devices were clean, working properly, and placed in her ears so that she could communicate with and understand others. . | 2014-02-01 | ||
| 11492 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 517 | F | 50Z111 | . NFPA 101 Life Safety Code 2000 Edition Chapter 19 Existing Health Care Occupancies 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire - NFPA 99 Standard for Health Care Facilities 1999 Edition Chapter 11 Health Care Emergency Preparedness 11-2 Purpose. The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan. 11-4.2 Senior Management. It shall be the responsibility of the senior management to provide its staff with plans necessary to respond to a disaster or an emergency. Senior management shall appoint an emergency preparedness committee, as appropriate, with the authority for writing, implementing, exercising, and evaluating the emergency preparedness plan. This standard is not met as evidenced by: Based on review of the facility's disaster and emergency evacuation plan, the facility did not have a detailed written disaster and emergency evacuation plan. Facility census: 81. Findings include: a) On 10/06/10 at approximately 12:45 p.m., a review of the facility's disaster and emergency evacuation plan was conducted. At this time, the disaster and emergency evacuation plan did not contain a detailed plan for the safety of residents and staff in the event of a disaster and emergency evacuation. The facility's evacuation procedures addressed vertical and horizontal evacuation within the building and not the evacuation from the building, in the event a complete evacuation would be required. | 2014-02-01 | ||
| 11493 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 456 | F | 50Z111 | . Based on observation, staff interview, and measurements of ambient room air temperatures, the facility failed to maintain heating boilers in a safe operating condition. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. At the time of this interview, the administrator and maintenance director related a plan for the installation of a temporarily heating boiler for use during the winter until permanent repair / replacement of the existing heating boiler system could be implemented. This process would take approximately three (3) weeks, during which the facility had to solicit competitive bids for a temporary heating boiler before a contract could be awarded to a outside vendor for installation. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. - d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. (See also citations at F224 and F257.) . | 2014-02-01 | ||
| 11494 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 257 | F | 50Z111 | . Based on observation, staff interviews, measuring of ambient air temperatures, and information from the National Weather Service, the facility failed to maintain comfortable and safe temperatures (between 71 and 81 degrees Fahrenheit (F)) throughout the building to minimize the risk of hypothermia. Ambient air temperatures in occupied resident rooms, measured in the presence of facility staff, were found to be below 65 degrees F. This deficient practice presented the potential for more than minimal harm to all residents in the facility and constitutes a finding of substandard quality of care. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/05/10 between 5:30 a.m. and 6:35 a.m., were as follows: B333 - 71 degrees F; B331 - 65 degrees F; B329 - 62 degrees F; B327 - 62 degrees F; B325 - 66 degrees F; B323 - 67 degrees F; B321 - 72 degrees F; B317 - 70 degrees F; B315 - 68 degrees F; B313 - 69 degrees F; B311 - 62 degrees F; B309 - 59 degrees F; B310 - 60 degrees F; B324 - 67 degrees F; B326 - 66 degrees F; B328 - 64 degrees F; B330 - 63 degrees F; B332 - 63 degrees F; C315 - 63 degrees F; C314 - 67 degrees F; C313 - 69 degrees F; C312 - 73 degrees F; C311 - 65 degrees F, C307 - 71 degrees F; C306 - 64 degrees F; C305 - 66 degrees F; C304 - 70 degrees F, C303 - 68 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 67 degrees F, C308 - 66 degrees F; C309 - 67 degrees F; C310 - 68 degrees F; C316 - 61 degrees F, C317 - 68 degrees F; B129 - 63 degrees F; B127 - 62 degrees F; B125 - 68 degrees F, B123 - 67 degrees F; B121 - 66 degrees F; B119 - 68 degrees F; B117 - 72 degrees F, B113 - 73 degrees F; B122 - 64 degrees F; B124 - 63 degrees F; B126 - 61 degrees F, C115 - 65 degrees F; C114 - 61 degrees F; C113 - 65 degrees F; C112 - 67 degrees F, C111 - 65 degrees F; C107 - 69 degrees F; C106 - 61 degrees F; C105 - 67 degrees F, C104 - 68 degrees F; C103 - 64 degrees F; C101 - 66 degrees F; C100 - 62 degrees F, C102 - 65 degrees F; C108 - 68 degrees F; C109 - 64 degrees F; C110 - 65 degrees F, C116 - 66 degrees F; C117 - 58 degrees F. According to the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/06/10 between 8:30 a.m. to 9:15 a.m., were as follows: B331 - 66 degrees F; B325 - 62 degrees F; B323 - 69 degrees F; B321 - 69 degrees F; B315 - 67 degrees F; B313 - 67 degrees F; B311 - 61 degrees F; B310 - 65 degrees F; B324 - 68 degrees F; B328 - 64 degrees F; B330 - 61 degrees F; C314 - 61 degrees F; C313 - 69 degrees F; C312 - 67 degrees F; C311 - 64 degrees F; C307 - 63 degrees F; C306 - 63 degrees F; C305 - 57 degrees F; C303 - 67 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 68 degrees F; C309 - 65 degrees F; C310 - 66 degrees F; B127 - 62 degrees F; B125 - 67 degrees F; B123 - 68 degrees F; B119 - 69 degrees F; B117 - 70 degrees F; B113 - 68 degrees F; B122 - 62 degrees F; B124 - 64 degrees F; B126 - 59 degrees F; B128 - 61 degrees F; C114 - 62 degrees F; C112 - 71 degrees F; C107 - 65 degrees F; C106 - 63 degrees F; C105 - 64 degrees F; C103 - 68 degrees F; C101 - 67 degrees F; C100 - 62 degrees F; C102 - 66 degrees F; C108 - 68 degrees F; C109 - 67 degrees F; C110 - 71 degrees F; C116 - 60 degrees F; C117 - 66 degrees F. d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. . | 2014-02-01 | ||
| 11495 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 224 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled "Heating back up plan" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted in the ambient air temperatures in resident rooms falling to unacceptably low levels, placing sixteen (16) of eighty-one (81) facility residents in immediate jeopardy of injury or death from hypothermia or other cold-related complications. The NIH warns in their 01/15/09 newsletter: "... Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." An article by the MFMER dated 06/09/09 and entitled "Hypothermia", states, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article identified risk factors associated with developing hypothermia to include age [AGE] years or older, mental impairment, certain medical conditions (e.g., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), severe arthritis, Parkinson ' s disease, spinal cord injuries, disorders that affect sensation in the extremities (including [MEDICAL CONDITION] in diabetics), dehydration, and any condition that limits activity or restrains the normal flow of blood), and the use of certain medications (e.g., antipsychotics). On 10/06/10 at 12:15 p.m., it was determined that residents had been sleeping in rooms with an ambient air temperature as low as 59 degrees Fahrenheit (F). Sixteen (16) facility residents, who were positive for one (1) or more risk factors for hypothermia and who had extended exposure to these unsafe temperatures, were determined to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F. The facility assessed these sixteen (16) residents as having body temperatures as low as 95.8 degrees F, placing them at risk for hypothermia. Information on hypothermia from CDC states: "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." The administrator was informed, at 12:15 p.m. on 10/06/10, that the facility's failure to provide a reliable source of heat to resident rooms placed more than an isolated number of residents in immediate jeopardy of injury or death, due to the potential for developing hypothermia. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve all occupied resident rooms, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. Upon removal of the immediate jeopardy, a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system without the use of portable electric space heaters. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Facility census: 81. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: "... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." The CDC states, "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." An article by the MFMER titled "Hypothermia" (06/09/09) ( ) noted, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article also identifies the following risk factors associated with developing hypothermia: "- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... "- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... "- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... "- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature." -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. . | 2014-02-01 | ||
| 11496 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 493 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timely manner resulted in findings of immediate jeopardy and substandard quality of care. It was determined, on 10/06/10 at 12:15 p.m., that residents residing in this unheated facility were placed in immediate jeopardy of harm or death related to the potential for developing hypothermia or other cold-related complications. Residents were found sleeping in rooms with ambient air temperatures as low as 59 degrees Fahrenheit (F). Sixteen (16) residents, who exhibited one (1) or more risk factors for developing hypothermia, were found to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F related to exposure to less than safe indoor temperatures. The governing body of this facility was ultimately responsible for the procurement, approval, and allocation of funding to maintain and ensure a safe and reliable heating system for this facility, as this entity alone possessed the authority to approve necessary repairs and/or replacement of this malfunctioning heating system. This practice affected sixteen (16) of eighty-one (81) residents currently residing in the facility. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: "... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." The CDC states, "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." An article by the MFMER titled "Hypothermia" (06/09/09) ( ) noted, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article also identifies the following risk factors associated with developing hypothermia: "- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... "- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... "- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... "- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature." -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. -- b) Review of facility documents found a request from the facility, dated 08/24/09, to replace a boiler which had been in operation since 10/94. The document from the governing body stated the funds were available and were awaiting "your okay". On 08/25/09, the chief operations officer (COO) of the governing body replied, "I don't see anything happening with this project until next summer so we would need to be able to fire the old boiler one more winter..." The facility replied, on 08/26/09, with, "Yes sir, to be honest I was afraid that we were not going to make it last winter and we almost did not, this boiler blew tubes and went down at least ten times last winter, every time we blow a tube the steam fills the boiler and then is followed by the cold water supplying the boiler... I do not believe that this boiler will last through the winter if we were able to get all of this repair work completed before cold sets in, I honestly believe that at this point we need to try to get a new boiler just like this one and switch them out..." As of the immediate jeopardy and substandard quality of care finding on 10/06/10, there was no indication the governing body had made any arrangements for the replacement of the boiler system, or the acquisition of an acceptable alternate heat source, to ensure residents were provided a safe and comfortable environment for the winter of 2010. . | 2014-02-01 | ||
| 11497 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 323 | D | 50Z111 | . Based on random observation and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as is possible. A nurse left a 50 cc bottle of liquid Dilantin on top of her medication cart, and left the cart parked and unsupervised at the unlocked nursing station. Resident #68 was observed to have unfettered access to the medication for approximately five (5) minutes. Facility census: 81. Findings include: a) Resident #68 Observations of the resident environment, on 10/06/10 at 8:08 p.m., noted Resident #68 wandering the resident hallway. She was observed to enter the unlocked nursing station and approach the medication cart parked there. No staff members were visible in the hallway or at the nursing station. The resident was approached and an attempt was made to redirect the resident's attention away from a bottle of medication sitting on top of the cart. The resident made inappropriate answers to questions but followed this surveyor out of the nursing station. After approximately five (5) minutes, a nurse was observed to exit a resident's room with a treatment cart. She was informed that Resident #68 was found unsupervised in the nursing station where a bottle of liquid medication was noted to be sitting on top of a medication cart. When asked what the medication was, the nurse (Employee #168) stated the bottle contained 50 cc of Dilantin 125/5ml. She stated she had not been given a key to the medication room to secure the medication. . | 2014-02-01 | ||
| 11498 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-12-02 | 431 | B | 50Z112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, "They rub it on me," while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, "No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use...". | 2014-02-01 | ||
| 11395 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 281 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, staff interview, and review of the Criteria for Determining Scope of Practice for Licensed Nurses published by the State licensing boards for registered professional nurses and licensed practical nurses (LPNs), the facility failed to provide services that meet professional standards of quality, as evidenced by the facility allowing an unknown employee to obtain intravenous access through an improper access site. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report dated 07/28/10 revealed an unknown employee had obtained intravenous access through Resident #109's port-a-cath without a physician's orders [REDACTED]. Review of the nurses note revealed no documentation of the incident and no clarification of the physician's orders. Review of the physician's orders [REDACTED]." Another hand-written entry, with no date, stating access port-a-cath times three (3) weeks after the following order: "[MEDICATION NAME] HCl 1 gram Intravenous (IV) - Q12H Everyday, 0900 2100: 1 gram Q12 [MEDICAL CONDITION]." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 3:00 p.m., revealed the DON agreed that a port-a-cath should never be used as an intravenous access site without a physician's orders [REDACTED]. Review of the Criteria for Determining Scope of Practice for Licensed Nurses, revised in 2009, revealed a Scope of Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse. Review of the Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse revealed a guideline stating: "Is there a written order from a licensed Physician, Physician's Assistant, or Advanced Practice Nurse or is there a signed written protocol? If No, report / defer to qualified individual." Further review also revealed a guideline stating: "Would a reasonable and prudent nurse perform the act? If No, report / defer to qualified individual." . | 2014-03-01 | ||
| 11396 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 309 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. . | 2014-03-01 | ||
| 11397 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 441 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control policies / procedures, review of the daily census report, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, as evidenced by improper cohorting of a resident with Methicillin-resistant Staphylococcus aureus (MRSA) with a compromised resident. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #13. Facility census: 108. Findings include: a) Resident #13 Review of Resident #13's medical record revealed she had been cohorted in a room with Resident #82, who was positive for MRSA since 10/29/10. Review of the daily census report revealed Resident #13 was moved to another room on 11/01/10. Review of the physician's orders [REDACTED]. Resident #13 was receiving the following treatments: "Cleanse left lower leg with soap and water. Apply [MEDICATION NAME] cream, [MEDICATION NAME], and netting 2x per day on 7-3 and 11-7. Check placement QS. - NS, DS Everyday." and "Cleanse right lower leg with soap and water. Apply [MEDICATION NAME], and netting 1 time per day 7-3. Check placement QS. - DS Everyday." Review of the facility's infection control policies / procedures revealed a resident with MRSA "may be placed with a 'low risk' individual. Low risk means that the resident would not be clinically compromised. Definition of non-compromised resident is one who does not have surgical or other wound / open area." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 1:20 p.m., revealed he did not feel that Resident #13 was "low risk",and he further stated the proper protocol would have been to place Resident #82 on contact precautions, remove Resident #13 from that room, and contact the physician. | 2014-03-01 | ||
| 11398 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2010-11-23 | 333 | D | D3L711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents were free of significant medication errors, when a resident's [MEDICATION NAME] (an anticoagulant) was not administered in accordance with physician's orders [REDACTED]. This was found for one (1) of six (6) records reviewed. Resident identifier: #99. Facility census: 128. Findings include: a) Resident #99 The medical record of Resident #99, when reviewed on 11/22/10 at 2:00 p.m., revealed this [AGE] year old woman had resided in the facility since 07/24/09 and was receiving [MEDICATION NAME] therapy for [MEDICAL CONDITION]. ([MEDICATION NAME] dosage is regulated based upon laboratory testing results designed to measure the blood clotting time and blood clotting factor.) Resident #99 was ordered a dosage of [MEDICATION NAME] for 1.5 mg by mouth every other day, alternating with [MEDICATION NAME] 3.0 mg by mouth every other day on 09/01/10. She was found to be stable on this dosage until lab results, dated 10/25/10, were elevated. A new order was written on 10/27/10, for [MEDICATION NAME] 3.0 mg by mouth on Day 1, then 1.5 mg by mouth on Days 2 and 3 on a repeating cycle, thus lowering the overall dosage. Documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/01/10, the monthly recapitulation (recap) of physician's orders [REDACTED]. Consequently, the [MEDICATION NAME] orders on the November 2010 MAR indicated [REDACTED]. The physician had ordered on [DATE] (when the dosage was lowered) that a repeat lab test be conducted in two (2) weeks, because of the elevated results observed on the 10/25/10 test. When the lab results were obtained on 11/10/10, they were still elevated, and the error was apparently recognized. The dosage was subsequently changed back to conform with the physician's orders [REDACTED]. The MAR for November 2010 confirmed Resident #99 received [MEDICATION NAME] per the 10/27/10 order on 11/10/10 through 11/30/10. The record revealed Resident #99 received the wrong dosage of the [MEDICATION NAME] for nine (9) days, with the potential for increased bleeding. - Interview with the facility's director of nursing (DON - Employee #17, on 11/23/10 at 11:20 p.m., confirmed the dosage of [MEDICATION NAME] administered to Resident #99 was incorrect for the first nine (9) days of November 2010. She indicated she would conduct further investigation and return to continue the discussion. On 11/23/10 at 11:27 a.m., the DON returned with a medication error report that had been completed by the facility on 11/10/10, confirming the conclusion reached during the initial record review. The medication error report stated Resident #99 received the incorrect dose for "approx (sic) 9 days." In response to the question "Could the error have endangered the life or welfare of the patient?" was checked "yes". Under "Explain" was written: "Increased (arrow pointing up) bleeding risk." | 2014-03-01 | ||
| 11399 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 278 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. . | 2014-03-01 | ||
| 11400 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 241 | D | FRRZ11 | Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. . | 2014-03-01 | ||
| 11401 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 279 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote "I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day." During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) and the MDS coordinator revealed this resident did not communicate well and would not be able to verbalize in this manner, and this statement and care plan did not accurately describe the resident's pain was not accurate. c) Resident #28 A review of the resident's medical record revealed [REDACTED]. A review of the resident's care plan revealed the hospice care plan was not integrated with the facility's care plan for the resident. . | 2014-03-01 | ||
| 11402 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 309 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. . | 2014-03-01 | ||
| 11403 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 441 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. . | 2014-03-01 | ||
| 11404 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 225 | D | FRRZ11 | Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, "he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks." The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, "Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided." The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. . | 2014-03-01 | ||
| 11405 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 279 | E | QWDA11 | . Based on observation, record review, and staff interview, the facility did not develop care plans for six (6) of seven sampled residents to provide justification for the residents to sit in the facility hallways in front of the nursing station to eat their meals. Resident identifiers: #19, #6, #26, #46, #45, and #44. Facility census: 75. Findings include: a) Residents #19, #6, #26, #46, #45, and #44 Observations, on 11/01/10 beginning at 12:15 p.m., found the above-identified six (6) residents sitting in front of the nursing stations in the hallways eating their lunch. Some of the residents were able to eat without assistance, and others were being fed by the staff. Four (4) residents (#6, #26, #46, and #45) were observed on the South hall, and two (2) residents (#19 and #44) were observed on the North hall. An interview with the director of nursing (DON), on 11/01/10 at 12:15 p.m., revealed the residents wanted to eat in the hallway in front of each nursing station. She further stated that some of the residents were unable to make the decision to eat in the hallway and the legal representative requested that the resident eat in the hallway in front of the nursing station. The DON also stated all of these residents had a care plan identifying the reason for each resident eating meals in this location. A review of the care plans these residents found no mention of eating their meals in the hallways. . | 2014-03-01 | ||
| 11406 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 309 | D | QWDA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of seven (7) sampled residents did not receive the influenza vaccine in accordance with the legal representative's wish to decline the vaccine due to an allergy. Resident identifier: #19. Facility census: 75. Findings include: a) Resident #19 Record review revealed a facility consent form titled "Vaccine Administration Authorization", upon which was recorded either acceptance or refusal to receiving the influenza vaccine, indicated that Resident #19's legal representative declined administration of the influenza vaccine, because the resident was allergic to it. On 10/21/10 at approximately 6:30 a.m., a nurse administered the influenza vaccine to the resident contrary to the wishes of the legal representative. At 8:00 a.m. on 10/21/10, Resident #19 became unconscious and was transferred to the hospital and admitted . Review of hospital records for Resident #19 revealed, "[AGE] year old female nursing home resident presented to the hospital after having two [MEDICAL CONDITION]. Patient had received [MEDICATION NAME] at the nursing home after getting the flu vaccine which she is allergic to. Patient had recently been taken off [MEDICATION NAME] which she was on for a number of years for agitation. Two weeks prior to having [MEDICAL CONDITION], [MEDICATION NAME] was discontinued abruptly and she was started on [MEDICATION NAME]. Patient was admitted and we restarted [MEDICATION NAME]." The hospital obtained an electrocardiogram (EKG), serial cardiac enzymes, CT of the brain, electroencephalogram (EEG), a chest X-ray, and blood work, and all results were within normal limits. An interview with the assistant director of nursing (ADON - Employee #32), on 11/01/10 at 1:30 p.m., revealed she was called to Resident #19's room after the influenza vaccine was administered to the resident by mistake at approximately 6:30 a.m. on 10/21/10. She immediately told the nurse to call the physician to obtain an order for [REDACTED]. The family of the resident had told her the resident was not allergic to eggs but was allergic to a preservative that was in the influenza vaccine and that she could not have the vaccine. The ADON also described the procedure the facility completed before administering the influenza vaccine, which involved gathering all consent forms for the vaccine and reviewing any allergies [REDACTED]. On the morning of 10/21/10, the nurse and the staff development coordinator had assembled the consent forms. The nurse had not reviewed the physician orders [REDACTED]. An interview with the director of nursing (DON), on 11/01/10 at 2:00 p.m., revealed, the nurse who administered the influenza vaccine to Resident #19 was no longer working at the facility. She further stated the nurse had not looked at the authorization form that indicated the resident was not to receive the vaccine and the nurse did not review the resident's physician orders [REDACTED]. An interview with the current staff development coordinator (Employee # 82), on 11/02/10 at 10:30 a.m., revealed he and another nurse had gathered vaccine administration authorization forms and the nurse was going to give the vaccine to the residents. The former staff development had asked them if they had reviewed the physician orders [REDACTED]. The nurse told him she had not looked at the physician orders [REDACTED]. He further stated the nurse apparently had not looked at the authorization form, because the resident received the vaccine and the authorization form indicated a refusal for the vaccine. A telephone interview with the facility's medical director, on 11/02/10 at 10:30 a.m., revealed he was not certain why the resident had the two (2) [MEDICAL CONDITION] after the flu vaccine was administered. The physician further reported he had never seen an influenza vaccine cause [MEDICAL CONDITION]. | 2014-03-01 | ||
| 11407 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-11-11 | 244 | E | VERC11 | . Based on review of resident council meeting minutes and staff interview, the facility failed to act upon a grievance made during a resident council meeting. On 09/27/10, residents expressed concerns regarding call lights not being answered during the midnight shift on Unit 4. This concern was not addressed by facility personnel. This practice had the potential to affect twenty-six (26) of twenty-six (26) residents who resided on Unit 4. Facility census: 107. Findings include: a) Review of the facility's 09/27/10 resident council meeting minutes, on 11/11/10, revealed residents expressed a concern regarding call lights not being answered on the midnight shift on Unit 4. Further review of the minutes revealed no evidence this concern had been acted upon by facility personnel. On 11/11/10 at 1:00 p.m., the administrator (Employee #16) was asked to provide evidence this issue had been addressed by the facility. At 1:10 p.m., Employee #16 reported the concern had not been acted upon as required. | 2014-03-01 | ||
| 11408 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 157 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused"). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Provide nebulizer treatments as ordered." Review of the facility's policy titled "Notification of Refused or Held Medications / Treatments" (policy #F-005, dated 10/15/05) found under the heading procedure: "A. When a medication / treatment cannot be administered as ordered, the prescriber must be notified." In an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) confirmed that nursing staff should have notified the physician that this resident was refusing her inhalation treatments at times. . | 2014-03-01 | ||
| 11409 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 225 | D | 50T311 | . Based on review of information from a criminal background check, staff interview, and review of a 2004 newsletter issued by the Office of Health Facility Licensure and Certification (OHFLAC) to all Medicare / Medicaid nursing facilities, the facility failed to ensure a West Virginia State Police background check was completed prior to hire for one (1) of one (1) background checks reviewed. Employee #123, a certified nurse practitioner (CNP), had been employed at this facility since May 2010, and no criminal background check by the West Virginia State Police had been completed as required by OHFLAC. Employee identifier: #123. Facility census: 118. Findings include: a) Employee #123 During a complaint investigation conducted at the facility between 11/08/10 and 11/11/10, it was discovered the facility had employed Employee #123 as a CNP since May 2010. Review of Employee #123's personnel record revealed the pre-employment screening conducted on this individual did not include a criminal background check by the West Virginia State Police in an effort to uncover a personal history of criminal convictions that may indicate this individual was unsuited for employment in a nursing facility. In an interview on the afternoon of 11/09/10, the facility's administrator (Employee #53) confirmed a criminal background check had not been conducted through the West Virginia State Police prior to hiring Employee #123. Review of a newsletter (dated November 2004), which had been distributed by OHFLAC to all Medicare / Medicaid certified nursing facilities in West Virginia, revealed the following directive: "... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. Individuals for whom criminal background investigations have been initiated may begin work at the facilities pending satisfactory outcomes of the checks. ..." . | 2014-03-01 | ||
| 11410 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 281 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of May 2002) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. . | 2014-03-01 | ||
| 11411 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 309 | G | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded "OK". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and "looked at the resident, then turned around and left the room", and one (1) of the nurses stated, "I'm sending her out of here. I'm leaving at 7:00." There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and "eyes not reactive to light accommodation". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of [DATE]) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was "Respiratory Arrest"; other signs and symptoms included "Decreased LOC". In the narrative section on page 1 of 6 was recorded, "Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..." Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, "Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending." Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of ",[DATE]") revealed the following: "Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident." "Procedure - Action Steps "1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) "2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. "3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. "4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. "5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) "6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. "7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions." According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as "nursing notes") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of "Change in Condition" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, "to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER." The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being "frail and alert oriented x 2" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: "blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed." At the end of this progress note was written: "Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable." - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: "[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting." and "IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)." The second sheet of orders contained one (1) set of entries as follows: "IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2." - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were "too accustomed to picking up the phone and calling EMS". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she "went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS." This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res | 2014-03-01 | ||
| 11412 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 328 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for [REDACTED].) - 3. Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of May 2002) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. (See also citation at F281.) - 4. A CNP progress note dated 10/13/10 (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated 10/14/10 (and electronically signed electronically at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is 135/738 (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on October 14, 2010 and end on October 18, 2010. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on October 14, 2010 and end on October 20, 2010." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on 10/14/10, with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on 10/14/10 (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated 10/14/10 was identified as having been an amendment to the earlier progress note at 1:57 p.m. on 10/14/10. This amendment, which was electronically signed by the CNP at 10:44 a.m. on 10/15/10, contained the exact same information as found on the earlier note for 10/14/10 under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." . | 2014-03-01 | ||
| 11413 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 514 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." - According to the AHIMA LTC documentation guidelines: "5.2.15. Condition Changes "Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical." The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #119's health status in accordance with professional standards of practice. -- 2. Review of the closed medical record for Resident #119, who was transferred to the hospital on the evening of [DATE] and subsequently expired, found a nursing note, dated [DATE] at 3:27 p.m., which contained six (6) separate late entries describing events said to have occurred one (1) week earlier between 1:00 p.m. and 5:00 p.m. on [DATE]. - According to the "as-worked" nursing schedule provided at 3:30 p.m. on [DATE] by the director of nursing (DON - Employee #81), the author of the late entries recorded on [DATE] (a licensed practical nurse (LPN - Employee #19)) worked from 7:00 a.m. to 7:30 p.m. on [DATE]. During the 7:00 a.m. to 7:30 p.m. shift on [DATE], Employee #19 recorded entries at 4:-0 (exact time not legible), 5:25 p.m., 7:00 p.m., and 7:22 p.m.; Employee #19 worked in the facility again from 7:00 a.m. to 7:30 p.m. on [DATE], and from 7:00 a.m. to 7:30 p.m. on [DATE] and would have been available to record these late entries more timely than she did. - According to the AHIMA LTC documentation guidelines: "5.3.2.1. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ... "When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes." The late entries recorded by Employee #19 were not entered into Resident #119's record as soon as possible (which would have been during the 7:00 a.m. to 7:30 p.m. shift on [DATE]. Instead, they were recorded seven (7) days after the resident expired. This significant delay in recording the late entries calls into question the reliability of their contents. -- 3. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on [DATE] following a prolonged hospital stay beginning on [DATE] during which she received treatment for acute [MEDICAL CONDITION] (ARF). Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. - Review of the [DATE] MAR found, for her only day present in the facility in September ([DATE]), she had an order to receive [MEDICATION NAME] inhalation treatments every six (6) hours (at regular intervals four (4) times a day). Review of the [DATE] MAR indicated [REDACTED]. - In an interview at 3:30 p.m. on [DATE], the DON reported the resident was to have received the inhalation treatments every four (4) hours and the physician orders [REDACTED]. - Review of a progress note dictated by the certified nurse practitioner (CNP), dated [DATE] and electronically signed at 2:39 p.m., found an entry stating to continue to nebulizer treatment for two (2) weeks and re-evaluate. Review of the physician orders [REDACTED]." Further review of physician orders [REDACTED]. Based on the information available in the resident's closed record, it is unclear when one (1) or more transcription errors may have occurred - when the CNP recorded the handwritten order to continue the [MEDICATION NAME] treatments on [DATE] (at a frequency different from what was specified in the resident's hospital discharge order), or when the order was carried over from the [DATE] MAR indicated [REDACTED] | 2014-03-01 | ||
| 11414 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2010-11-18 | 311 | D | 0ZJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used. | 2014-03-01 | ||
| 11415 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 309 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who was no longer affiliated with the facility) and made an appointment to have her evaluated. - Record review revealed a nursing note, dated 04/28/10 at 5:30 p.m., which stated, "... Resident C/O (complained of) sore tongue (sic) slightly red / inflamed. (Name of attending physician) notified (sic) new order [MEDICATION NAME] 10 mg x 2 weeks - resident notified." On 04/29/10 at 1:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont(inued) for mouth soreness. No complaints at this time." On 04/29/10 at 7:40 a.m., a nurse wrote, "... [MEDICATION NAME] to begin this AM (morning) for sore mouth, tongue slightly red and irritated. ..." On 04/29/10 at 4:00 p.m., a nurse wrote, "... [MEDICATION NAME] cont /s (without) adverse effects noted r/t (related to) sore touth (sic), tongue - slightly red / irritated - denies any further C/O (complaints). ..." On 04/30/10 at 8:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont /c (with) no adverse effects noted for sore mouth, tongue slightly red, irritated. Denies any C/O this AM. ..." On 04/30/10 at 11:30 a.m., a nurse wrote, "Dtr (daughter) made appt (appointment) today /c (name of outside physician) at 1:30 p - follow-up (sic). Facility to take." On 04/30/10 at 3:00 p.m., a nurse wrote, "Returned back from (name of outside physician). Dx (diagnosis): glossitis, mouth ulcers, possible candidias (sic). New orders OK per (name of facility's physician): (1) [MEDICATION NAME] xylocane (sic) 1 tablespoon swish, gargle, and swallow QID (four times a day) x 10 days. (2) [MEDICATION NAME] 150 mg qday (sic) (every day) x 3 days. (3) 2 cc B12 IM (intramuscular injection) in AM. (4) 80 mg [MEDICATION NAME] IM x 1. (5) [MEDICATION NAME] oral susp(ension) 1 tsp QID PO (by mouth) swish, gargle, and swallow x 10 days. Dtr notified. Cont to monitor." This entry was followed by an addendum, dated 04/30/10, noting the discontinuation of the [MEDICATION NAME]. - The nursing entries from 04/28/10 until 04/30/10 only addressed the resident's irritated tongue and did not contain evidence of an assessment of the resident's oral cavity as a whole; there was no mention of the presence of mouth ulcers which had been identified by the outside physician on the afternoon of 04/30/10. - In an interview on 11/16/10 at 8:45 a.m., the director of nursing (DON - Employee #88) reported the nurses had assessed the resident's mouth and only found that the resident had an irritated tongue. A nurse called the facility's physician and told him about the irritated tongue, and he ordered [MEDICATION NAME]. The DON provided, as evidence of assessment of the resident's oral cavity, a nursing assessment form (which include an oral / nutritional assessment) dated 02/27/10. However, this nursing assessment was completed two (2) month before the resident was diagnosed by the outside physician as having a glossitis, mouth ulcers, and possible candidiasis, for which he ordered treatment with five (5) medications. The DON further stated the facility's physician was in and visited the resident on 04/26/10, and there was no evidence the resident had complained about a sore mouth at that time. - A review of the physician's progress notes found an entry, dated 04/26/10, which did not indicate the resident had complained of a sore mouth. This physician visit, however, occurred two (2) days prior to the resident's first complaint of a sore mouth on 04/28/10. - A review of the monthly summary completed, by a licensed nurse on 04/05/10, revealed a section titled "16. Oral Hygiene". Within this section was "Condition of Mouth" followed by a space where a description of findings could be recorded; this space was left blank. - Review of nursing notes entered in the medical record after the resident returned from her outpatient physician visit on the afternoon of 04/30/10 with orders to treat found references to the resident's complaints of mouth pain or discomfort in entries made at 4:00 p.m. on 05/01/10, at 6:20 a.m. on 05/02/10, at 9:50 a.m. on 05/02/10, and at 4:00 p.m. on 05/02/10. However, there were no entries describing the physical condition of the resident's oral cavity until 10:00 p.m. on 05/03/10, when a nurse wrote: "... Cont to have observable mouth ulcerations /c C/O discomfort..." - Resident #153's daughter, after hearing complaints of oral pain and soreness from the resident and after hearing a report by her brother of the presence of sores in her mother's mouth, reported having asked facility staff to have the attending physician evaluate her. The facility failed to provide a full assessment, either by a registered nurse or the physician, of the resident's oral cavity after the resident complained of pain and soreness to her mouth. The resident's daughter was required to intervene and schedule an appointment with an outside physician in order to obtain appropriate treatment for [REDACTED]. -- b) Resident #73 During the observation of the passing of medications at 9:00 a.m. on 11/10/10, the licensed practical nurse (LPN - Employee #13) failed to administer [MEDICATION NAME] 25 mg which was ordered to be given at that time to Resident #73. The nurse surveyor compared the list of medications verbally told to her by the LPN during the medication pass (and observed being given to the resident) with the physician's orders [REDACTED]. Employee #13 continued on with her medication pass to the remaining residents on the B hall. During an interview with Employee #13 at 9:50 a.m. on 11/10/10, after she had completed the pass, she acknowledged she had not administered the [MEDICATION NAME]. She reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A comparison of the medications in the medication cart labeled for use by Resident #73 with the resident's MAR indicated [REDACTED] . | 2014-03-01 | ||
| 11416 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 315 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of "very cloudy and dark" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with the presence of an indwelling urinary catheter, and she had NOT been diagnosed with [REDACTED]. -- According to her care plan dated [DATE] through [DATE], the interdisciplinary team identified the following problem: "Risk for infection R/T (related to) indwelling foley (sic) cath (sic) and hx (history) of uti (sic)." The goal associated with this problem statement was: "Resident will exhibit no s/sx (signs / symptoms) of UTI thru next review aeb (as evidenced by) afebrile, no change in sedimentation of urine." The interventions intended to assistant the resident in achieving this goal included: "#16F foley (sic) with 30cc balloon per orders, Change Q (every) 4 weeks and prn (as needed). change (sic) urinary drainage bag Q 4 weeks and prn. Foley cath care Q shift. Provide incontinence cares (sic) frequently as able ensuring proper peri care due to increased risk of ecoli (sic) infection. Encourage and assist with fluids with and between meals for preventative measures. Monitor for s/sx of UTI such as hematuria (blood in urine), dysuria (painful urination), pyuria (pus in urine), abdominal pain, temp (sic), increasd (sic) confusion, etc. Notify MD as needed. hx (sic) of vre ([MEDICATION NAME]-resistant [MEDICATION NAME]). Monitor for s/s of uti (sic) during periods of increased blood sugars. Notify md (sic) of findings." -- A nursing note, dated [DATE] at 12:30 a.m., revealed, "Temp (temperature) 100.2 (symbol for 'oral') ... Urine very cloudy and dark. New order (sic) UA (urinalysis) & C&S (culture and sensitivity) this AM (morning) ...." A nursing note, dated [DATE] at 11:15 p.m., stated, "Labs returned. Abnormal UA - pH 9.0, Protein 75, Blood 250, Leukocyte Est 500 preliminary (sic) awaiting final." (The normal ranges for these labs are: pH = 4XXX,[DATE].0, Protein = negative (0), Blood = negative (0), and Leukocyte Est = negative (0).) The next consecutive entry in the nursing notes, dated [DATE] at 12:20 a.m., stated, "Temp 97.6 (Ax) (axillary). Foley catheter draining cloudy dark yellow." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, " ... yells / moans @ (at) times (sic) complaints generally nonspecific and cease /c (with) conversation. T (temperature) 99.0 (symbol for 'oral') awaiting final C&S of UA. foley (sic) cath patent (sic) draining tea colored urine. denies (sic) abd(ominal) pain upon palpation. C/O (complains of) bladder feeling full (sic) abd small & soft. ... fluids (sic) encouraged by staff as well as ice chips ... will continue to monitor." The next consecutive entry, dated [DATE] at 4:00 p.m., stated, "Temp 98.6 (Ax). ... Yells / moans out occas (occasionally) /c C/O mouth pain. ... ice chips & fluids encouraged. foley (sic) cath patent draining dark tea colored urine - slightly blood tinged. Awaiting C&S of UA. ..." The next three (3) consecutive entries in the nursing notes (dated [DATE] at 6:20 a.m., [DATE] at 9:50 a.m., and [DATE] at 4:00 p.m.) contained no mention of the status or characteristics of the resident's urinary output. The next entry, dated [DATE] at 2:10 a.m., stated, " ... Indwelling foley (sic) drng (draining) small - mod amts of dk sl amber urine. ..." The next consecutive entry in the nursing notes, dated [DATE] at 10:00 a.m., stated, "Temp 99.6 (Ax). Lethargic. C/O not feeling well (sic) not wanting to be bothered." An addendum following this entry stated, "10 am. Received napoxen (sic) ([MEDICATION NAME] - a non-steroidal anti-[MEDICAL CONDITION] drug) @ 7:45 a.m. Will cont to monitor for S/Sx fever; infection." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, "Up to BSC (bedside commode) (sic) became very weak, pale. Put back to bed. BP (blood pressure) ,[DATE]. P (pulse) 84. Skin cool (sic) clammy. After stimulation BP ,[DATE] P 82. Had expelled hard BM (bowel movement) prior to episode." The next consecutive entry, dated [DATE] at 11:30 a.m., stated, "Yelling (sic) insisting to be back up on BSC. ..." This was followed by an entry by the same author with the same date and time, noting that a dose of [MEDICATION NAME] was withheld related to a possible adverse effect. The next consecutive entry, dated [DATE] at 10:00 p.m., stated, " ... also C/O feeling very weak - orders rec (received) for lab wk (work) in AM (morning). Res (resident) made aware." The next consecutive entry, dated [DATE] at 4:00 a.m., stated, "Resting quietly in bed - awakens easily (sic) appears sl (slightly) listless. ... Ate 0% of meals [DATE] /c only (approx) 300 ml of fluids /c meals ..." The next consecutive entry, dated [DATE] at 5:00 a.m., noted the arrival of the vendor laboratory service to collect specimens for blood work. The next consecutive entry, dated [DATE] at 10:00 a.m., stated, "Lethargic. BS (blood sugar) elevated. BP low. Consulted Dr. (name of attending physician) /c exam. New order. Novalog ,[DATE] 10 units bid (twice daily). IV (intravenous fluids) 0.45% NaCl @ 100 cc/hr x 2 hours then 80 cc/hr. Transfer to (name of hospital) ER for eval." The next four (4) entries in the nursing notes recorded the successful insertion of the IV, notification of the resident's change in condition and transfer to the resident's legal representative, transfer of the resident to the hospital, and mailing of the notice of transfer and bedhold policy to the resident's legal representative. -- The above nursing notes recorded evidence of the resident exhibiting signs and symptoms of a UTI beginning on [DATE] (e.g., dark, cloudy urine; blood in urine; low grade temperature; lethargy). These signs and symptoms continued without treatment or physician intervention from [DATE] until [DATE], when the resident was transferred to the hospital. -- Review of a lab specimen inquiry dated [DATE] with a run time of 1146 (11:46 a.m.) revealed the following abnormal results of the blood work collected in the early morning hours of [DATE]: - Glucose - 354 (normal range ,[DATE]) - Blood urea nitrogen (BUN) - 194 (normal range ,[DATE]) Below this lab value on the report was typed, "Tried to notify Sunbrige (sic) of results - could not get pick-up on floor. Notified (name) (front desk) that I would be faxing results to floor. ..." - Creatinine - 5.1 (normal range 0XXX,[DATE].3) - B/C (BUN / Creatinine) Ratio - 38 (normal range ,[DATE]) - Potassium - 5.1 (normal range 3XXX,[DATE].5) -- Lab results after Resident #153 arrived at the hospital revealed the following: - Urine specimen collected on [DATE] (with results dated [DATE]) - the appearance was noted to be "turbid (cloudy) specimen red" with "large" amount of blood, equal to or greater than 300 mg/dl of protein in the urine, with a quantity of red blood cells in the urine "too numerous to count" and "loaded" with bacteria. - Blood specimen collected on [DATE] (with results dated [DATE]) - cultured positive for [DIAGNOSES REDACTED] pneumoniae and Streptococcus mitis group. The resident was septic and subsequently expired at the hospital on [DATE]. -- An interview with the director of nursing (DON - Employee #88), on [DATE] at 8:45 a.m., revealed the resident's attending physician would always wait until the final lab report was received to determine what antibiotic to order. She further stated the physician would treat if a resident were symptomatic, but according to the DON, Resident #153 only had an elevated temperature on [DATE] and was not symptomatic of a UTI. -- Resident #153 was exhibiting signs and symptoms of a UTI beginning on [DATE] and continuing to [DATE], when the resident was transferred to the hospital. There was no evidence to reflect staff notified the attending physician of the resident's dark, cloudy urine, the presence of blood in the resident's urine, the resident's moaning and yelling, her lethargy, and/or of the overall change in the resident's condition prior to [DATE]. . | 2014-03-01 | ||
| 11417 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 323 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: "Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage." The goal associated with this problem statement, with a target date of 08/18/10, was: "Will have no injury r/t falls thru next review." Interventions to achieve this goal included: "up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders." Review of her physician orders [REDACTED]." -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, "Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..." -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. A hospital operation summary, dated 08/19/10, stated, "The patient is a [AGE] year-old female who is known to me. Approximately a year ago, she sustained an intertrochanteric hip fracture while getting out of bed. ... She was admitted to an outside hospital and found to have a subtrochanteric femur fracture as above. She is extremely and morbidly obese. She does not really ambulate and has not ambulated for some time because of this. ..." -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." In a statement dated 08/15/10 at "12:15 about" (per the author of the statement), Employee #22 (a nursing assistant) wrote: "I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)." In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: "CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived." In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: "Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval." In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: "On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..." There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. (See also citation at F225.) -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, "The resident sustained [REDACTED]." -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resides in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She also stated, "I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling." -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, "The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor." -- A review of the "Owner's Operating and Maintenance" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the "sit-to-stand lift") revealed a "Safety Summary" on pages 4 and 5, which included the following in a box labeled "Warning": "DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. "Individuals that use the Standing Sling (Model R130) MUST be able to support the majority of their own weight, otherwise injury can occur. ..." In the section titled "Transferring From" on page 10, under the heading "Lifting the Patient (Figure 1)" were the following instruction to be performed before raising a resident above the surface being transferred from: "F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place." In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the "maximum open position") during the transfer of Resident #54, contrary to the manufacturer's instructions. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, "When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand." She further stated, "We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position." Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. . | 2014-03-01 | ||
| 11418 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 520 | E | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility census: 98. Findings include: a) Review of facility abuse / neglect self-reporting to State officials, on 11/11/10 at 9:30 a.m., revealed an incident that took place on 08/15/10 and was reported to the Office of Health Facility Licensure and Certification (OHFLAC, the State survey and certification agency) as an "unusual occurrence". Resident #54 sustained a fracture during an attempted transfer using a sit-to-stand lift. Documentation on the "Immediate Fax Reporting of Allegations" form, in the section headed "Brief description of the incident", stated: "Called to resident's room by staff. Resident holding on to bar of sit to stand (sic) with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor and squad called to take resident to ER (emergency room ) for eval." This form was signed by a registered nurse (RN - Employee #135). - The "Five-day Follow-up" form was completed on 08/18/10 by the facility's social worker (Employee #142). Documentation in the section headed "Outcome / Results of Investigation" stated: "Unusual occurrence - resident slid during attempted transfer. No indication that maltreatment occurred. Resident stated that she let go of handle bar of lift (sit to stand)." There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. - Two (2) written statements were included with the facility's reports from the nursing assistants who had been attempting the transfer. In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." - Review of all documentation associated with the facility's internal investigation found it was unclear how Resident #54 ended up on the floor. Employee #92 stated, "She then let go with the other hand and slid down to the floor." The description by the RN (Employee #135) stated, "Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor ... " There was no evidence of any investigation into statements by staff members of problems with using the sit-to-stand lift when transferring residents into and out of an electric bed, which apparently contributed to the resident's fall. -- b) A review of facility incident / accident reports, on 11/15/10 at 10:30 a.m., revealed an incident report for Resident #54 categorized as a fall, which documented the incident of 08/15/10 at 12:45 p.m. Documentation in the section headed "Describe the circumstances of the event and what actions, if any have been taken currently" stated, "Called to resident's room by staff. Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident was lowered to floor. Unable to move by staff and and squad was called to assist resident. 4 squad members and 2 RN, 1 LPN, 2 CNA (certified nursing assistants) assisted resident on back board and stretcher, support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated 'I am not in w/c (wheelchair) right.' Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor, unable to obtain VS (vital signs) D/T (due to) positioning." Documentation in the section headed "Recommendations to prevent further falls" stated: "Use mechanical lift for transfers." A hand written statement was attached to the report, composed by an RN (#111) and dated 08/16/10. It stated: "(Name of Employee #92), (name of Employee #134), and (name of Employee #81) were re-educated on the sit to stand lift following the (name of Resident #54) fall (sic) RMS (Risk Management System) # 1." There was no apparent investigation of the problem of using a sit-to-stand lift in conjunction with an electric bed. There was no reason given why it was recommended that a mechanical lift should be used with Resident #54 after the fall, instead of the sit-to-stand lift. There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. There was no explanation as to why it was necessary to provide re-education to only these three (3) employees (if nothing had been done improperly); if any re-education were felt to be warranted, there was no explanation as to why this re-education was not then provided to all staff that might use the sit-to-stand lift. -- c) Record review revealed Resident #54 was a [AGE] year old female who was 5' 1" tall and weighed between 280# and 301# during her residency in this facility; at the time of this survey event, Resident #54 resided in another facility. Resident #54 was interviewed via telephone at 9:55 a.m. on 11/16/10. She was asked about the incident of 08/15/10, which she said she recalled clearly. She stated that, when she was being moved in the lift, the lift tipped or lurched, causing her "to go over". She also reported her belief that the lift was broken at the time is was being used. -- d) During an interview with the director of nursing (DON - Employee #88) on 11/16/10 at 11:00 a.m., she stated there were some beds in the facility with which the sit-to-stand lift could not be used. She said the sit-to-stand lift could not be used with the electric beds, because the legs of the lift could not be fully opened when they were under the bed. She demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. -- e) The manufacturer's operating manual for the sit-to-stand lift was reviewed at 10:00 a.m. on 11/16/10. In the section headed "Lifting the patient", was Step F, which stated: "Make sure the legs are in the maximum open position and the shifter handle is locked in place." -- f) An interview was conducted, on 11/16/10 at 10:29 a.m., with the two (2) nursing assistants involved in the above-referenced event (Employees #92 and #134). They both stated that the legs of the sit-to-stand lift were not in the open position when they lifted Resident #54 from the bed and attempted to transfer her to the wheelchair and back. -- g) The facility's administrator (Employee #28), when interviewed on 11/15/10 at 2:30 p.m., was asked if the facility's QAA committee had topics that were always placed on the agenda for discussion by the committee members. He related there were items looked at in every meeting, which included past survey results, customer base, incidents / accidents, abuse / neglect reporting, medication errors, and department-specific topics related to their operations. Discrepancies found by the surveyor during an investigation into the events of 08/15/10, which included a review of written statements obtained by the facility from individual staff members, information obtained by the surveyor through interviews with staff members and a telephone interview with Resident #54, and a review of facility documentation, identified concerns related to the use by staff of the sit-to-stand lift during Resident #54's transfer resulting in a [MEDICAL CONDITION]. These discrepancies were discussed with the administrator, who was asked to provide to the surveyor any additional documentation not previously produced, to demonstrate the circumstances of Resident #54's transfer and fall were reviewed by facility management and/or the QAA committee and steps were taken to ensure no other residents were injured in the future during the use of the sit-to-stand lift. He voiced understanding and stated he had spoken with Resident #54 following the events of 08/15/10, and that she had not said anything to him about the lift tipping or lurching. He stated he had notes of this conversation. He subsequently provided: (1) a "Customer First Ambassador Rounds Worksheet", which he stated was the discussion with the resident when she returned from the hospital; (2) the facility's incident report of 08/15/10; and (3) a policy entitled "Resident / Patient Lifting / Transfer". - Upon review of Resident #54's "Customer First Ambassador Rounds Worksheet", this form consisted of observations and interviews conducted by the social worker (Employee #142) on 08/25/10, 08/26/10, 08/27/10, 09/13/10, 09/15/10, and 09/17/10. The interview questions were general satisfaction items, such as "Was the food appetizing in taste?", "Has the housekeeping staff kept you room to your satisfaction?", "Has the staff been taking good care of you?" The observations were also general in nature, covering areas such as hygiene and grooming, environment, and water pitchers. There was nothing found that addressed the incident of 08/15/10. - Review of the facility incident report provided by the administrator found that additional pages were attached, to include a cover sheet containing the signatures of the administrator and the DON, indicating they had reviewed the investigation of the incident. - Review of the facility's "Resident / Patient Lifting / Transfer" policy found it covered all aspects of lifting and transfer. The only specific mention of the sit-to-stand lift was under Section 4 for "Equipment", which stated: "Sit to-Stand Lifts - designed to assist the caregiver in standing a resident / patient up, without the need for any manual lifting. The resident / patient only needs minimal weight bearing ability to be transferred easily from bed to toilet or chair." There were no specific policies or procedures presented regarding appropriate use and safe operation of the sit-to-stand lift. There was no documented training or education provided to address whether the sit-to-stand lift should not be used with some beds (e.g., electric) or that the legs of the lift must be fully opened before lifting a resident. | 2014-03-01 |