CMS-Nursing-Home-Full-Deficiencies
Data source: Big Local News · About: big-local-datasette
This data as json, copyable, CSV
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 498 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 578 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's advance directives, communicated via the Physician order [REDACTED]. Resident identifier: #38. Facility census: 100. Findings included: a) Resident #38 Review of the medical record found the Resident lacked capacity to make medical decisions, and her son was her legal representative. Review of the current POST form noted the Resident did not wish to be resuscitated, have comfort measures, a feeding tube, or IV fluids for a trial period of no longer than 3-5 days. Under the heading, signature of Patient/Resident, the form noted verbal consent was obtained from (Name of son) via phone on 09/29/19. The physician signed the POST form on 08/01/19, although the POST form indicated the Resident's son did not complete the form until 09/29/19. The date the form was prepared by a facility nurse was 07/29/19. The resident's electronic medical record as well as the current care plan directed, do not attempt resuscitation, or comfort measures. Review of the instructions for the 2016 edition entitled, Using the POST form, section D, found: The patient or representative/surrogate and physician/APRN (Advanced Practice Registered Nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. The physician/APRN then prints his/her name, phone number, and the date and time the orders were written. On 01/29/20 at 10:10 AM, the facility social worker (SW) #81 verified the Resident's son did not sign the POST form. SW #81 said she did not know anything about the POST form because she was not present when the POST form was completed. The POST form was discussed with the administrator at 8:06 AM on [DATE]. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 499 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 580 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record interview and interview, the facility failed to notify the physician when medications were held for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found the resident was ordered to receive [MEDICATION NAME] 5/325 milligrams (mg) via the feeding tube three times daily for pain and [MEDICATION NAME] 0.25 mg via feeding tube three times a day for anxiety. Review of Resident #98's nurses progress notes found on 10/31/19 at 6:55 PM, a Licensed Practical Nurse (LPN) #138 held the [MEDICATION NAME] and [MEDICATION NAME]. Note attached to the holding of [MEDICATION NAME] and [MEDICATION NAME] as follows: Medication held due to drowsiness, spoke with son and he was also in agreement to hold the medication. There was no documentation the physician was notified of the withholding of the medication. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:15 PM, they verified after reviewing the medical records for Resident #98, the physician had not been notified of the withholding of [MEDICATION NAME] and [MEDICATION NAME] on 10/31/19. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 500 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 584 | D | 0 | 1 | CN2N11 | Based on record review and interview, the facility failed to ensure reasonable care for the protection of resident's personal property from loss or theft for one (1) of one (1) resident reviewed for the care area of personal property. Resident identifier: #58. Facility census: 100. Findings included: a) Resident #58 On 0[DATE] 03:01 PM, the Resident's son said he had no problems with the facility other than, They lose clothes in laundry sometimes they find them, sometimes not. It's just aggravating not a big problem. I have been labeling them myself. Sometimes they don't label them, and I think that is what causes the problem. Review of the notes in the electronic medical record found a progress note, dated 06/27/19 at 9:14 AM, during a care conference for the resident, his son raised his concern that his mother had some articles of clothing that are missing. At 11:44 AM on 01/28/20, the Social Worker (SW) #33 confirmed she could not find information to indicate the investigation into the allegation of missing clothing. SW #33 said someone at the facility should have completed a complaint form, then this allegation would have been assigned to someone in environmental services. She said if an item is missing and we can confirm the Resident had the item, the facility would reimburse the family member or replace the missing item. At 8:06 AM on [DATE], the Administrator was informed of the above information. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 501 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 623 | D | 0 | 1 | CN2N11 | Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of a resident's transfer to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Resident #[AGE] A record review for Resident #[AGE] on 01/28/20, revealed two (2) Minimum Data Sets dated [DATE] and 12/24/20 for transfer to an acute care hospital. Further review indicated there had been no notifications of these hospitalization s sent to the Ombudsman. On 02/03/20 at 1:52 PM, the Nursing Home Administrator (NHA) verified there were no notices sent to the Ombudsman for hospitalization s on [DATE] and 12/24/19. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 502 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 641 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for three of 20 residents. Resident identifiers: #99, #38, #98. Facility census: 100. Findings included: a) Resident #99 Review of Resident #99's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/12/20, stated the resident had two (2) Stage 2 pressure ulcers. Resident #99's Pressure Ulcer Reassessment dated [DATE], documented a Stage 4 pressure ulcer on the left buttock. An initial Pressure Ulcer Assessment also performed on 01/07/20 documented a new unstageable pressure ulcer on Resident #99's sacrum. Resident #99's Pressure Ulcer Reassessments dated 01/14/20 documented a Stage 4 pressure ulcer on the left buttock and a Stage 3 pressure ulcer on the left buttock. During an interview on 02/03/20 at 11:46 AM, the Regional Director of Operations stated Resident #99's MDS with ARD 1/12/20 was incorrect. She stated Resident #99 did not have two (2) Stage 2 pressure ulcers at that time. No further information was provided through the completion of the survey. b) Resident #38 Review of Resident's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19, coded the resident as receiving an anticoagulant for 2 days during the assessment period. Review of the Medication Administration Record [REDACTED]. At 2:26 PM on 01/29/20, during an interview with the nursing coordinator #139, it was confirmed the MDS was incorrectly coded, and the resident did not receive an anticoagulant. c) Resident #98 Review of the Resident's medical record found a comprehensive (5-day) minimum data set (MDS) with an assessment reference date (ARD) of [DATE], coded as the Resident received a hypnotic medication. Review of the November 2019, physician orders [REDACTED]. At 01/31/20 at 12:54 pm, the MDS registered nurse employee #139, confirmed the MDS was incorrect. In addition, E #139 confirmed the resident was not ordered a hypnotic. E #139 said she would correct this MDS error. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 503 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 656 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a person-centered comprehensive care plan for one of twenty (20) residents reviewed. The care plan for Resident #57 was not developed for the [DIAGNOSES REDACTED].#57. Facility census: 100. Findings included: a) Resident #57 A record review on 01/29/20, revealed the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/20, indicated the Resident had a [DIAGNOSES REDACTED]. During an interview on 01/29/20 at 11:15 AM, the Director of Nursing (DON) verified the care plan had not been developed for the [DIAGNOSES REDACTED].#57. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 504 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 657 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan for one of 20 residents reviewed. Resident identifier: #17. Facility census: 100. Findings included: a) Resident #17 Review of Resident #17's comprehensive care plan revealed the following focus, (Resident's name) has an ADL Self Care Performance Deficit r/t (related to) stroke, left [MEDICAL CONDITION]. Interventions included, Bathing: The resident requires 1 staff participation with bathing.Resident receives a shower on Monday/Thursday and a bed bath the remaining days. Review of Resident #17's task report for January 2020, revealed she received showers on Tuesdays and Fridays. During an interview on 01/29/20 at 9:49 AM, the Director of Nursing (DON) verified Resident #17 received showers on Tuesdays and Fridays, but her care plan stated she received showers on Mondays and Thursdays. The DON stated she would update the care plan to reflect Resident #17 received showers on Tuesdays and Fridays. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 505 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 684 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (1) of five (5) residents discharged from the facility received treatment and care in accordance with professional standards of practice. Nursing staff failed to follow physician's orders [REDACTED]. Resident identifier: #103. Facility census: 100. Findings included: a) Resident #103 Record review found the Resident was admitted to the facility on [DATE]. The Resident was discharged to home on 07/12/19. On 06/25/19 the physician wrote an order for [REDACTED].>Accu-Check ac and hs; notify FNP (family nurse practioner) or MD ( if greater than 350 or less than [AGE]. before meals and at bedtime. This order remained in effect until the Resident was discharged on [DATE]. Review of the Medication Administration Record [REDACTED]. On the following dates and times, the Resident's blood sugar (BS) was over 350 and the physician was not notified: --06/25/19 at 9:00 PM, BS- 392 --06/26/19 at 11:30 AM, BS - 399 --06/26/19 at 5:30 PM, BS - 387 --06/26/19 at 9:00 PM, BS - 400 --06/27/19 at 11:30 AM, BS 396 --06/27/19 at 5:30 PM, BS - 3[AGE] --06/28/19 at 11:30 AM, BS - 371 --07/01/19 at 5:30 PM, BS - 390 --07/02/19 at 9:00 PM, BS - 392 --07/03/19 at 5:30 PM, BS - 389 --07/03/19 at 9:00 PM, BS - 399 --07/06/19 at 9:00 PM, BS - 370 --07/07/19 at 9:00 PM, BS - 367 --07/09/19 at 11:30 AM, BS - 366 --07/11/19 at 9:00 PM, BS - 394 On 15 occasions during the resident's 19 day stay at the facility the Resident's BS was over 350 and the physician was not notified. In addition the Resident's blood sugar was over 400 on two (2) occasions when the physician was contacted. On 06/25/19 the physician was contacted for a blood sugar reading of 404 at 5:30 PM. New orders were written to start sliding scale [MED] ([MEDICATION NAME]) for 7 days and give 10 units of [MEDICATION NAME] at this time. Sliding scale [MED] was to be administered per sliding scale at 7:30 AM, 11:30 AM, 5:30 PM and 9:00 AM. There was no indication on the MAR indicated [REDACTED]. This new order noted the physician should be contacted when BS was over 400. However, the original order continued on the MAR indicated [REDACTED]. On 07/06/19 a new order was written to give [MEDICATION NAME] solution 100 unit/ML, sliding scale at 9:00 AM and 9:00 PM. On 07/06/19 at 9:00 PM the BS was recorded as 387 under this order. But at the same time the Resident's BS was recorded to be 370 on another order at 9:00 PM. At 2:00 PM on 01/28/20, during an interivew with the Director of Nursing (DON) reviewed the MAR's with the surveyor. The DON confirmed the facility did not notify the physician when the resident's BS was over 350 on 15 occasions as directed by the order on the MAR. The DON was unable to find evidence the Resident received 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. The DON said a onetime order should have been written to give the 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. On 02/03/20 03:59 PM, the Resident's physician reviewed the orders with the surveyor. The physician confirmed there was no evidence to indicate he was contacted when the Resident's BS was over 350. The physician said, He (indicating the Resident) had a long acting [MED] also so I would not have changed any orders had I known. At 8:30 AM on [DATE], the above issues were presented to the administrator. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 506 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 690 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate treatment for [REDACTED]. In addition, this placed the resident at risk for developing antibiotic-resistance. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100,000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. A review of the Medication Administration Record [REDACTED]. Review of the C&S report found [MEDICATION NAME] (Cipro) is Resistant (R) to E coli and not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 507 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 693 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure water flushes, for a resident with a feeding tube, were provided as directed by the physician. This was true for one (1) of two (2) residents reviewed for the care area of feeding tube. Resident identifier: #98. Facility Census: 100. Findings included: a) Resident #98 Review of Resident #98's, record found she was admitted to the facility on [DATE]. Record review also revealed, the resident was to have nothing by mouth (NPO) and received all of her nutrition and fluids through the feeding tube due to a prior [MEDICAL CONDITIONS]. Physician order [REDACTED]. --10/07/19 through 10/11/19- Water flushes via the tube feeding- 90 cubic centimeters (cc) every six (6) hours-12 am- 6 am- 12 pm- 6 pm. --10/12/19 through current - Water flushes via the tube feeding- 1[AGE] cc every four (4) hours-12 am- 4 am- 8 am- 11 am- 5 pm and 8pm. Review of Resident #98's Medication Administration Record [REDACTED] --10/07/19 at 6 pm. --10/11/19 at 4 pm. --10/14/19 at 4 pm. --10/16/19 at 4 pm. --10/23/19 at 12 pm. --11/01/19 at 8 am. --11/04/19 at 8 am. --11/25/19 at 8 am. --[DATE] at 4 pm. --12/04/19 at 8 am. --12/06/19 at 11 am. --12/09/19 at 5 pm. --12/13/19 at 5 pm. --[DATE] at 5 pm. --12/22/19 at 8 am. --12/24/19 at 8 am and 11 am. --[DATE] at 11 am. --12/29/19 at 8 am and 11 am. --01/03/20 at 8 am and 11 am. --01/06/20 at 11 am. --0[DATE] at 11 am and 5 pm. --01/13/20 at 5 pm. --[DATE] at 5 pm. --01/20/20 at 11 am and 5 pm. --01/24/20 at 11 am. On 02/03/20 at 1:15 pm, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) verified, after review of the medical records for Resident #98, the water flushes as mentioned above had not been given due to [MEDICAL TREATMENT] treatments. The physician/registered dietician had not been notified to arrange water flushes to accommodate her [MEDICAL TREATMENT] treatments to ensure the proper hydration was maintained. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 508 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 697 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage the resident's pain in accordance with facility policy and physician order. This was true for one (1) of three (3) of residents reviewed for the care area of pain. Resident identifier: #17. Facility census: 100. Findings included: a) Policy Review According to the facility's policy entitled, Medication Administration - general guidelines with effective date 1/1/17 When PRN medications are administered, the following documentation is provided: .Complaints or symptoms for which the medication was given, including any nonpharmacologic interventions attempted by the nursing staff prior to administration of the PRN medication. b) Resident #17 Review of Resident #17's physician's orders [REDACTED]. Resident #17 also had an order initiated 03/01/19 to evaluate for signs and symptoms of pain every four (4) hours. This pain assessment was performed daily at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. From January 1, 2020, through January 14, 2020, Resident #17's pain was assessed as 0 on a scale from 1-10. A score of 0 indicates the absence of pain. On 01/13/20 Resident #17's [MED] with [MEDICATION NAME] order was changed from a scheduled order three times per day to one tablet by mouth every six hours as needed for pain. For this medication, the MAR indicated [REDACTED]. On 01/14/20, Resident #17's pain assessment order was changed to evaluate for signs and symptoms of pain every six (6) hours. This pain assessment was performed daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident #17's pain was assessed as 0 on a scale from 1-10 at each assessment from 01/14/20 through 01/28/20. On 01/14/20 at 6:55 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 6, on a scale from 1-10. The medication was documented as effective. On [DATE] at 8:07 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 01/20/20 at 7:39 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/21/20 at 9:04 AM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/22/20 at 8:02 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 0[DATE] at 8:31 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 0, on a scale from 1-10. The medication was documented as effective. On 01/24/20, Resident's [MED] with [MEDICATION NAME] order was changed to one (1) tablet by mouth every six (6) hours as needed for pain, administer after repositioning for pain is ineffective. For this medication, the MAR indicated [REDACTED]. On 01/25/20 at 10:30 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 01/26/20 at 9:50 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 0[DATE] at 9:01 PM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. During an interview on 01/29/20 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #17's pain was not assessed prior to receiving as needed pain medication on 01/25/20, 01/26/20, and 0[DATE]. The DON acknowledged the resident's every six (6) hour pain assessments documented no pain and were performed at 12:00 AM, 6:00 AM, 12:00 PM. and 6:00 PM, and not when the as needed pain medication was administered. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 509 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 698 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received Phosphorus supplements as requested. This failed practice had the potential to affect a limited numer of residents. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical record found on [DATE] at 10:23 AM, the [MEDICAL TREATMENT] center physician requested a phosphorus supplement due to the resident's phosphorus level being low at 2. The facility Nurse Practitioner (NP) was notified on [DATE] at 2:17 PM, and said, The nephrologist needs to recommend what phosphorus supplement he wants. On 01/02/20 at 12:16 pm, the [MEDICAL TREATMENT] center was notified concerning what phosphorus supplement the nephrologist wanted. The [MEDICAL TREATMENT] center responded with, (Nephrologist Name) is out of town and will not return till 01/13/20. The Resident's medical record contained no documentation the attending physician was consulted for a phosphorus supplement. In addition, no further communication between the [MEDICAL TREATMENT] center and the facility concerning the phosphorus could be found. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:30 pm, they confirmed there was no documentation to indicate the attending physician was notified concerning a phosphorus supplement. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 510 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 726 | F | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure nursing staff possess the competencies and skills sets to recognize proper antibiotic use to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 511 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 758 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's [MEDICAL CONDITION] medication regimen was managed and monitored to promote or maintain the resident's highest level of mental, physical, and psychosocial well-being for four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #40, #38, #98, #57. Facility census: 100. Findings included: a) Resident (R) #40 Record review indicated the facility's physician did not appropriately respond to the Gradual Dose Reduction (GDR) for [MEDICATION NAME] ([MEDICAL CONDITION] medication, selective serotonin reuptake inhibitor used to treat anxiety and depression) recommended by the pharmacist on the on the Medication Regimen Review (MRR) for 01/16/2020. The MRR completed on 01/16/2020 by the pharmacist noted the last GDR evaluation for [MEDICATION NAME] was on 0[DATE] was contraindicated by the physician. The last dose adjustment was on 12/09/19 at which time the physician increased the [MEDICATION NAME] dose from 10mg to 15mg at bedtime (HS). The pharmacist indicated, Residents [MEDICATION NAME] 15 mg HS is due for GDR evaluation which must be attempted unless clinically contraindicated. The physician signed the MRR on 1/20/20 and left the form blank without providing any further comments to indicate his response to the GDR, or any further action to be taken. Review of the Resident's Mediation Administration Record on 02/03/2020 at 10:00 AM, revealed R #40 had been receiving [MEDICATION NAME] 15mg at bedtime for major [MEDICAL CONDITION] since [DATE] through current with no decrease in dose. On 01/29/20 at 12:25 PM, during an interview Regional Director of Operations #129 reviewed and verified the GDR recommendation dated 01/16/2020 was not appropriately acknowledged or completed by the physician. During an interview on 01/29/2020 at 12:35 PM, the Director of Nursing (DON) reviewed the GDR on the MRR dated 01/16/2020, and agreed the physician did not appropriately respond, and the GDR was incomplete. The DON stated, How could you know what he (physician) wanted done? He never filed the comment section or any of the check boxes to say if he agreed or disagreed. This should have been caught. The DON further explained, The facility's new procedure for processing MRR with GDR recommendation is for the pharmacy to review Resident's Medication Regimen, do their recommendations, then the provider addresses the recommendations, and then it is passed down to the Clinical Care Supervisor to ensure the orders are put through. The DON verified nursing staff have not been signing off on the actual MRR/ GDR paperwork, they (nursing) only enter the order and their name will appear on that specific order in the electronic medical record. b) Resident #38 Review of the Resident's medical record found the Resident is receiving [MEDICATION NAME] 0.5 milligrams (mg's), give 1 tablet by mouth, two times a day (BID) related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. Review of the nursing notes, dated 05/07/19, found an entry, (Name of physician) in facility; new orders to increase [MEDICATION NAME] to 0.5 mg. BID; [MEDICATION NAME] cream to face [MEDICAL CONDITION] QS. (Quantum satis (abbreviation q.s. or Q.S.) is a Latin term meaning the amount which is enough. It has its origins as a quantity specification in medicine and pharmacology, where a similar term quantum sufficit (as much as is sufficient) has been used (abbreviated Q.S.) Review of the facility's psychopharmacological medication monitoring logs for May 2019 continuing to January 2020 found the order: Monitor effectiveness of antipsychotic medication ([MEDICATION NAME]) as evidence by patient is free of behaviors, delusions, every day and night shift. The specific behaviors for which the antipsychotic medication, [MEDICATION NAME], was administered was not specified. The daily documentation on the MAR indicated [REDACTED]. Review of the current care plan, revised on 08/03/19, found the problem: (Name of Resident) received antipsychotic medications ([MEDICATION NAME]) related to behavior management as evidenced by wandering, attempting to provide care to other residents. On 01/29/20 at 12:33 PM, the Director of Nursing (DON) was asked to provide evidence the Resident had an increase in behaviors at the time of the increase in [MEDICATION NAME]. The DON said the resident was scratching her face at the time of the increase in medication. The DON said, We were monitoring that as a condition rather than a behavior. On 02/03/20 at 4:00 PM, the Resident's physician was interviewed regarding the increase in [MEDICATION NAME]. The physician reviewed his progress notes scanned into the medical record at the time of the increase. The physician verified no notes, written by himself, were scanned in the electronic medical record on or around 05/08/19. He said he must have written a note regarding the increase in [MEDICATION NAME] but the facility did not scan in his notes. The physician stated, Let me go see if I have any notes around that time. At approximately 4:45 PM on 02/03/20, the physician returned with a typed note for an acute visit dated 05/07/19. This progress note said the patient was scratching, picking at her face and neck, she was standing at the mirror with wash cloth scrubbing left side of her face when we walked into her room, she states, I'm just trying to get all the stuff off. The physician said the medication was increased due to daily self injurious behaviors of picking/scratching her face until she bleeds. On [DATE] at 8:02 AM, the above information was discussed with the Administrator. At the close of the survey on [DATE] at 12:30 PM, no further information was provided by the facility. d) Resident #57 A record review for Resident #57 on 01/29/20, revealed a Gradual Dose Reduction (GDR) dated 08/14/19, recommended decreasing [MEDICATION NAME] from 20 milligrams (mg) to 10 (mg). On 09/09/19 the facility Medical Director (MD) had agreed and signed to decrease [MEDICATION NAME] to 10mg. [MEDICATION NAME] was decreased to 10 mg on 09/30/19. In an interview with the Director of Nursing (DON) on 01/29/20 01:12 PM, verified the order to decrease Celaxa was not completed in a timely manner. c) Resident #98 Review of Resident #98's medication regimen found the resident is currently receiving [MEDICATION NAME] 25 milligrams (mg) three times daily, effective date was [DATE]. Further review found the resident's [MEDICATION NAME] was increased from 25 mg twice daily to three times daily on [DATE]. There was no documented behaviors to indicate the need to increase the medication. Since the increase, the resident continues to have no behaviors to indicate the continued use of the medication. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 12:30 pm, confirmed there was no documented behaviors for Resident #98 to indicate the increase of [MEDICATION NAME]. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 512 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 761 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with facility policay for one (1) of eight (8) [MED]'s stored in the B-hallway medication cart. Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Policy Review The facility's policy entitled, Vials and [MEDICATION NAME] of Injectable Medications with effective date 01/01/2017 stated, When a vial is opened, the licensed nurse records the opened date on the vial. b) Resident #[AGE] On 01/28/20 at 9:08 AM, the B-hall medication cart was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Resident #[AGE]'s [MEDICATION NAME] Solution Pen-injector ([MED] [MEDICATION NAME]) was not dated when opened. LPN #[AGE] confirmed Resident #[AGE]'s [MED] pen-injector was not dated when opened. The facility's Administrator was informed of the above findings on 01/28/20 at 9:34 AM. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 513 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 773 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of laboratory results outside of the clinical reference range for Resident #98. Additionally, the facility failed to obtain laboratory testing for Resident #57, as directed per physician's orders [REDACTED]. Resident identifiers: #98 and #57. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found an order to obtain an ammonia level. This level was obtained on [DATE] at 3:31 pm. The ammonia level was [AGE] which was critically high. Normal ammonia level is 9-35. Review of the progress notes found the attending physician was not notified of the labortory results until 10/21/19 at 5:11 pm. An interview with the Director of Nursing, on 01/30/20 at 1:10 pm, confirmed, after the review of Resident #98's medical record, there was a delay in notifying the physician of a critical lab. b) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician had ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100.000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. Review of the Medication Administration Record [REDACTED]. Review of the C& S, [MEDICATION NAME] (Cipro) is Resistant (R) to E coli an not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 514 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 812 | F | 0 | 1 | CN2N11 | Based on observation and interview, the facility failed to store, prepare, distribute and serve food in a manner to protect for food service safety. During the kitchen tour it was discovered the floor of the reach-in refrigerator had food particles and cardboard stuck to the floor. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 100. Findings included: a) Kitchen tour During the kitchen tour on 0[DATE] at 11:24 AM, it was discovered the reach-in refrigerator to be unclean, with food particles and cardboard stuck to the floor. This failed practice provided for unsanitary storage for refrigerated foods. In an interview on 0[DATE] at 11:24 AM with the Dietary Manager (DM), she verified the refrigerator was dirty and needed to be cleaned. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 515 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 868 | F | 0 | 1 | CN2N11 | Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee consisted of the required members. The medical director (MD) or his/her designee did not attend quarterly QAA meetings. This had the potential to affect all residents. Facility census: 100. Findings included: a) QAA Review of the signatures on the attendance sheets for QAA meetings found the medical director only attended 2 quarterly QAA meetings from January 2019 - January 2020. The MD attended meetings held on 10/24/19 and a meeting dated July 2019. The actual date of the meeting was not included on the signature sheet. On [DATE] at 8:07 AM, the Administrator confirmed signature sheets showed the MD only attended 2 quarterly QAA meetings for the year. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 516 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 880 | F | 0 | 1 | CN2N11 | Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 100. Findings included: a) B-hallway medication room On 01/28/20 at 9:08 AM, the B-hallway medication room was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Under the sink were stored two (2) cartons with six (6) cups of applesauce in each carton. LPN #[AGE] removed the applesauce from under the sink. On 01/28/20 at 9:34 AM, the facility's Administrator was informed that applesauce was stored in an unsanitary area under the medication room sink. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 517 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 881 | K | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sensitivity was received and appropriate antibiotic was ordered by facility's physician/staff. The facility's abatement plan of correction consisted of the following: 1. Resident # 57 was identified as being affected by the alleged deficient practice of failing to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].#57 physician was notified immediately by the Director of Nurses (DON) on 1/29/2020. Resident #57 physician current course of treatment implemented was to obtain a UA with C & S this was completed on 1/29/2020 by the Unit Charge Nurse (UCN). The Unit Charge Nurse obtained an order for [REDACTED]. Quality Standards Nursing Coordinator educated the Director of Nurses (DON), Clinical Care Supervisor (CCS), and Registered Nursing Assessment Coordinator (RNAC) on antibiotic stewardship data base, documentation expectations, and follow through immediately on 1/30/2020. All Unit Charge Nurses on duty will be educated immediately by a Quality Standards Nursing Coordinator on 1/30/2020 on reading/interrupting a UA with C & S lab results, documentation expectations, communication with physician on lab results, and follow through. Nurse Practitioner examined Resident #57 and reviewed findings with physician in person on 1/30/2020. The CCS or designee will obtain C & S results from the lab by 2/3/2020. The CCS or designee will immediately upon receipt of lab results will report to physician or nurse practitioner for further orders as necessary. 2. DON or designee will educate all nurses at the being of each shift prior to going to the floor until all nurses have been educated starting 1/30/2020 - 2/3/2020. Any nurse on leave of absence will be educated immediately upon return to work prior to going to the floor to provide care. Quality Standards Nursing Coordinator completed an audit of current antibiotic use on 1/29/2020 and no other residents were identified as being affected by the alleged deficient practice. The nurse receiving lab results will review results with the physician or nurse practitioner by the end of the shift. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The UCN must contact the physician or nurse practitioner and obtain new orders within accordance with antibiotic stewardship. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The CCS or designee will monitor antibiotic stewardship to ensure diagnostic results have been obtained and the physician or nurse practitioner was made aware and required documentation is completed daily. Antibiotic Stewardship data base will be reviewed daily by the CCS or RNAC or designee daily. 3. The DON will review all findings and report in QAA monthly for follow up to assure POC is effective. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 518 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 583 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of a resident's clinical record. An unauthorized disclosure of Resident#6's clinical record, without Resident#6's consent or knowledge, was given by accident to another resident's family member to take to a consulting physician's appointment. This is true for one (1) of one (1) resident reviewed for privacy and confidentiality. This practice had the potential to affect more than a limited number of residents. Resident identifier: #6. Census: 85. Findings included: a) Resident #6 On 04/16/18 at 1:05 PM, an interview with the Ombudsman information concerning issues that had been brought to the Ombudsman's attention. The Ombudsman stated it was revealed a resident's family member had mistakenly been given another resident's clinical records to take with them to a doctor's appointment. On 04/16/18 at 2:38 PM, an interview with Resident#3's daughter-in-law revealed, upon arriving with Resident #3 at a doctor's appointment in another city, it was discovered she had mistakenly been given Resident #3's roommates medical records to take to the appointment. The daughter-in-law had requested Resident#3 records, but by mistake was given Resident#6's medical records. The daughter-in-law said she returned the records back to the facility, when she returned the resident (Resident #3) back to the facility. Resident#3's daughter-in-law said, she was asked by the facility to not tell Resident #6 (the roommate of Resident #3) what had occurred. The daughter-in-law, also a nurse, said she was very upset about the incident and told the facility she was concerned her mother-in-laws records could also be compromised. On 04/18/18 at 9:30 AM, review of all Resident Council meeting minutes; all Incident/Accident logs; all Grievances/Complaint/Concern logs and reports; and all Reportable incidents with related investigations for the past six (6) months, revealed no incidents or grievances concerning an incident of a resident accidently receiving another resident's medical record to take with them to an appointment. An interview with the director of nursing (DON), on 04/19/18 at 11:29 AM, revealed the DON was aware and confirmed the incident did occur, and that it was a HIPAA (Health Insurance Portability and Accountability Act) violation. The DON, said a nurse accidently gave Resident #3's daughter-in-law Resident#6 medical records, instead of Resident#3's medical records. When asked why it was not logged on the grievance log, the DON said she did not know, but it should have been. | 2020-09-01 |
| 519 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 585 | E | 1 | 0 | DQUX11 | > Based on staff interview, family interview, and record review, the facility failed to promptly address complaints/grievances to resolution and keep the residents appropriately apprised of progress toward resolution of complaints/grievances. This was evident by the lack of documentation of any follow up regarding resident council grievances and concerns; lack of a grievance filed concerning a staff member hanging up on a resident's family member where disciplinary action was taken against the staff member; and failure to promptly address a complaint of finding several feces soiled items stored in a resident's room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, and #9. Census: 85. Findings included: a) Resident #9 On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. SW#124 said They do it different here, they bring up issues and deal with it right then and there at the meeting. SW#124 left the room to get the Resident Council President, Resident #9. Resident #9 entered the room alone. SW#124 did not return. The Resident Council President was asked by this surveyor, If there is anything you would like to share with us? Resident #9 said, I guess. They said you wanted to know in meetings we just tell them when something is wrong, and they just write it down. When asked if they get back to the council with resolutions or outcomes involving concerns that were discussed. Resident #9 said, I guess, I don't know, we talk about things. The surveyor asked, Has there been any issues of food being served cold? The Resident Council President said, The food was cold just the other day, and one day last week, everyone in dining hall was talking about it This surveyor asked, Do they follow up when you have concerns or issues? Resident #9 said, I don't know. I guess, they talk about it. If you have an issue we tell the Activities supervisor. I've been telling her for a while I need pants, some of mine are missing, and some got ruined with bleach. I never did get them, so I told my family, and they are going to get some pants for me. Review of grievances or resident council minutes did not show Resident#9 had any issues concerning missing pants or pants ruined by bleach. This surveyor informed SW#124 the outcome of the interview with the Resident Council President, and SW#124 said that was the first she heard about Resident #9's pants and she would immediately take care of it. b) Grievance not addressed An interview with the Ombudsman on 04/16/18 at 1:05PM, revealed a resident's family medical power of attorney (MPOA) had a complaint regarding a Social Worker hanging up on her while trying to get some answers concerning the care of her mother. The family member told the ombudsman that she had called the administrator and the corporate office, and neither would return her calls. Review of Resident council meeting minutes, Complaint/grievance/Concern files, Incident/accident reports, and reportable incidents and related investigations for the past six (6) months, on 04/18/18 at 9:30 AM, revealed no evidence of any grievances or complaint concerning an incident of a staff member being rude and/or hanging up on a resident's family member calling to inquiry about issues concerning their loved one. There was no evidence given to this surveyor of a written facility's acknowledgment of the resident's MPOA family member's complaint or grievance. There was no evidence of a written grievance decision that included the date the grievance was received, a summary statement of the resident's MPOA's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's MPOA's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or the date the written decision was issued. On 04/18/18 at 9:54 AM, review of an employee disciplinary notice dated 02/26/18, revealed a notice involving Social Worker (SW#90) concerning 'rudeness employee/residents/ family/visitors'. According to the disciplinary notice, the employer statement alledged SW#90 hung up on a family member of a resident. The incident occurred on 02/21/18. SW#90 disagreed with the employer's description of the violation, noting the reason as I hung up after thanking her for calling and listening to her yell and holler and try to help her. I got off phone to keep from being rude. Review of grievances and concerns did not reveal a grievance listed or filed concerning the incident described in this disciplinary notice. c) Resident #1 During a family interviw on 04/16/18 at 1:03 p.m. it was revealed the facility staff had not ensured resident cabinets and drawers were free from soiled clothing. This would then create odors in the resident's room that would be presenyt when they came to visit. This issue had been brought to the staff's attention but had not be resovled as yet. Review of the resident's care plan on 04/19/18 at 9:00 a.m. revealed the staff had identifed and was care planning for a problem with the resident removing soiled clothing and putting them in the closet or drawere in the room. The intervention was listed as staff was to monitor the areas every shift. This was not being implemented. An inservice for employuees which was regarding checking for soiled linens left in resident's closets or drawers was held on 12/24/17. | 2020-09-01 |
| 520 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 609 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 521 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 610 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 522 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 745 | E | 1 | 0 | DQUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to provide medically related social services regarding timely notification of care plan meetings to ensure attendance and participation of residents and/or resident's family members responsible for making decisions concerning resident care. The facility also failed to provide medically related social services to assist residents and/or resident's family members responsible for making decisions in voicing and obtaining resolution to complaints and grievances. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, #4, #5, and #6. Census: 85. Findings included: Both surveyors on the investigative team conducted an interview, on 04/17/18 at 1:10 PM, with two (2) of the joint Medical Power of Attorneys (MPOAs) for Resident #1. The interview revealed they do get letters notifying them of care plan meetings. The MPOAs issues and concerns where they were not being notified in enough time to make any arrangements at work, so they could attend the care plan meetings. They said they might get a letter on Friday, for a meeting scheduled for the following Monday. They both confirmed it is just too hard to get off work and make any arrangements with such a short notice. The MPOAs revealed an incident where they arrived on the date and time the letter indicated, and as they sat waiting for the meeting, they were informed the meeting had already taken place on a different day. The MPOAs said the facility did go ahead and meet with them that day, because they refused to leave until they did. The MPOAs said they have shared these concerns about timely care plan meeting notices with staff before. Review of grievance and concern records did not reveal any of these issues or concerns had been identified, filed, and/or addressed. On 04/17/18 at 5:10 PM, an interview with Social Worker (SW#62), revealed the following. SW#62 said, I try to send out the notices for care plan meetings a month out. This surveyor requested the last care plan notices sent for Residents #4, #5, and #6. Resident #4 was deemed not to have capacity to make medical decisions due to short term memory loss, disorientation, inability to process information, caused by alcoholic [MEDICAL CONDITION], and dementia. Review of last care plan meeting notice sent for Resident #4 to resident's Medical Power of Attorney (MPOA), was dated 02/27/18, Tuesday, for a care plan meeting scheduled two (2) days later 03/01/18, Thursday. Review of last care plan meeting notice sent to Resident #5's MPOA was dated 02/19/18, Monday, for a care plan meeting scheduled for three (3) days later 02/22/18, Thursday. SW#62 said Resident #6 had capacity and SW#62 hand delivered the care plan meeting notice to Resident #6 himself when she resided at the facility. SW#62 agreed a two (2) or three (3) day notice was not a sufficient amount of time to expect MPOAs or health care surrogates to make any arrangements to attend scheduled care plan meetings. Review of Multidisciplinary care conference progress note for Resident #4, dated 03/01/18, stated under Patient/Responsible Party Invitation/Response: (name of MPOA) invited chose not to attend. Review of Multidisciplinary care conference progress note for Resident #5, dated 03/01/18, stated under Patient/Responsible Party Invitation/Response: (name of responsible party) invited via mail but unable to attend. b) Resolution to complaints and grievances On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. The Resident Council President was asked if the facility gets back to the council with resolutions or outcomes involving concerns that were discussed. The Resident Council President answered she guessed they did, however she went on to describe a recurring problem that had been discussed about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it. The Resident Council President went on to say she had been telling the activities supervisor for a while she needed pants because some of hers were missing, and some got ruined with bleach. The Resident Council President said, I never did get them, so I told my family, and they are going to get some pants for me. Review of grievances did not show the Resident Council President had any issues concerning missing pants or pants ruined by bleach. This surveyor informed SW#124 the outcome of the interview with the Resident Council President, and SW#124 said that was the first she heard about Resident #9's pants and she would immediately take care of it. An interview with the Ombudsman, on 04/16/18 at 1:05PM, revealed a grievance reported to the Ombudsman concerning a Social Worker hanging up on a resident's family medical power of attorney (MPOA) while trying to get some answers concerning the care of her mother. The family member told the ombudsman that she had called the administrator and the corporate office, and neither would return her calls. Review of Resident council meeting minutes, Complaint/grievance/Concern files, Incident/accident reports, and reportable incidents and related investigations for the past six (6) months, on 04/18/18 at 9:30 AM, revealed no evidence of any grievances or complaint concerning an incident of a staff member being rude and/or hanging up on a resident's family member calling to inquiry about issues concerning their loved one. There was no evidence given to this surveyor of a written complaint or grievance filed concerning this incident. There was no evidence of a written grievance decision that included the date the grievance was received, a summary statement of the resident's MPOA's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's MPOA's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or the date the written decision was issued. On 04/18/18 at 9:54 AM, review of an employee disciplinary notice dated 02/26/18, revealed a notice involving Social Worker (SW#90) concerning 'rudeness employee/residents/ family/visitors'. According to the disciplinary notice, the employer statement alleged SW#90 hung up on a family member of a resident. The incident occurred on 02/21/18. SW#90 disagreed with the employer's description of the violation, noting the reason as I hung up after thanking her for calling and listening to her yell and holler and try to help her. I got off phone to keep from being rude. Review of grievances and concerns did not reveal a grievance listed or filed concerning the incident described in this disciplinary notice. | 2020-09-01 |
| 523 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 804 | E | 1 | 0 | DQUX11 | > Based on observation, staff interview, family interview and record review, the facility failed to serve foods that are at proper temperature and palatable. This practice has the potential to affect more than a limited number of residents are consume foods served from this central location. Census: 85. Findings included: a) Review of resident council minutes on 04/18/18 revealed the residents had expressed concern with the food being cold. Such things as coffee being cold was listed in the 03/02/18 meeting and then food being cold if you ate in the room. Chicken noodle soup was described as being poured staight out of the can and not heated. b) Confidential family interview on 04/16/18 after lunch revealed the food does not always look appealing or appetizing. Sandwiches will often be a piece of bread with a slice of lunch meat on it. Did not have condiments or anythisg else on the sandwich. c) This was reviewed with the dietary manager on 04/18 /18 in the morning. She verified the residents had expressed concern about cold foods in resident council meetings and they have been attempting to resolve the issue. d) These issues were discussed with the director of nursing and the corporate regional director of operations on 04/18 /18 in the afternoon. e) Random confidential resident interviews During the initial tour on 04/16/18 at 12:45 PM, observations and interviews with several randomly chosen residents having lunch in their rooms revealed complaints of food being served cold. One resident stated, Lunch is warm today, but it is not always. Another resident said, Sometimes it's cold, the meals were sometimes cold on a few days last week. A different resident shared, Most of the time it (meals) is cold. On 04/17/18 at 3:59 PM, an interview with the Resident Council President revealed a recurring problem about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it. | 2020-09-01 |
| 524 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 880 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to implement proper infection control monitoring. Soiled clothing was left in Resident #1's drawers and closets creating an infection control concern. This was evident for one (1) of four (4) sampled residents currently in the faciilty. Census: 85. Findings included: a) Resident #1 During the investigation confidential interviews were conducted with family members on 04/16/18 in the afternoon. It was found that Resident #1 was known to remove soiled clothing and place them in the drawer or closet in their room. This issue was known to staff and the care plan interventions required staff to monitor the draweres and closets in the room every shift for soiled clothing and perform visual checks of the area. This was not being implemented and soiled cloting is still being left in these areas and family will come in and notice odors which are coming from the soiled clothing. This procendure could lead to an infection control issue and soiled clothing is not being handled using proper infection control techniques. The issue was discussed with the director of nursing on 04/17/18 in the afternoon. An inservice was conducted on 12/24/17 but this has still not corrected the problem. | 2020-09-01 |
| 525 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 241 | D | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding. | 2020-09-01 |
| 526 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 279 | D | 0 | 1 | FJSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away. | 2020-09-01 |
| 527 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 371 | E | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been. | 2020-09-01 |
| 528 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 431 | D | 0 | 1 | FJSP11 | Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened and/or to be discarded. She stated the policy required it to be labeled when it is first used with the discard date. The DON says that she has a plan to fix this problem. | 2020-09-01 |
| 529 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 574 | E | 0 | 1 | J9FW11 | Based on observation, staff interview and information from the resident council meeting, the facility failed to provide information on how to contact the local ombudsman. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) Resident council meeting During the resident council meeting on 11/28/18 at 10:27 AM, the residents in attendance did not know how to contact the ombudsman if they would choose to do so. The facility's Social Worker (SW) #28, was also in attendance at the council meeting. SW #28 told the resident's the name and contact information of the local ombudsman was posted at the nurses station. After the meeting was adjourned, at 10:52 AM on 11/28/18, the SW and the surveyor reviewed the information posted at the nurses station. The name and contact information of the local ombudsman was not available. On 11/28/18 at 03:03 PM, the administrator said the contact information of the local ombudsman, Was posted but someone removed it, we have put it back. | 2020-09-01 |
| 530 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 583 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #245's medical record was kept confidential. Resident #245's medication orders were observed to be hanging on the magnetic bulletin board in the residents room. This was a random opportunity for discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 Observation of Resident #245's room at 12:34 p.m. on 11/26/18 found her medication list placed on her magnetic bulletin board with a magnet. The list had been printed by the facility and it appeared Resident #245's daughter had placed it on the board with a hand written note which read, Mom's Medications, and No [MEDICATION NAME]. An additional observation with the Director of Nursing (DON) at 1:05 p.m. on 11/27/18, found the medication list was still on the magnetic bulletin board in Resident #245's room. The DON removed the list and indicated it looked like Resident #245's daughter had placed the list there and she would call and talk to them about it. She agreed the medication should not have been posted in the residents room. | 2020-09-01 |
| 531 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 584 | D | 0 | 1 | J9FW11 | Based on observation and staff interview the facility failed to ensure Resident #245's wheelchair was in good prepare. The wheelchair was missing an arm rest on one side and the other arm rest was loose. This was a random opportunity of discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 An observation of Resident #245's wheelchair at 9:40 a.m. with the Director of Nursing (DON) found the arm rest on the left side of her wheelchair was missing and the residents right arm rest on her wheelchair was loose. The DON stated, I will have (name of Maintenance Director) to fix it right away. | 2020-09-01 |
| 532 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 622 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to convey all required transfer information to the receiving hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #43. Facility census: 97. Findings include: a) Resident #43 On 09/17/18 at 5:18 am, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. The Acute Care Transfer form provided to the receiving hospital did not include information regarding usual mental status, ambulation status, skin condition at time of transfer, devices and special treatments. The Acute Care Transfer form contained sections to provide this information. However, the sections were blank. During an interview on11/27/18 at 12:20 PM, the Director of Nursing agreed the information had not been completed on Resident #43's Acute Care Transfer form dated 09/17/18. | 2020-09-01 |
| 533 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 641 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview the facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for six (6) of twenty-six (26) resident's MDSs reviewed during the Long Term Survey Process (LTCSP). Resident #96's MDS was inaccurate in the area of death in the facility. Resident #14 MDS was inaccurate in area of pressure ulcers. Resident #9's MDS was inaccurate in area of falls. Resident #95's MDS was inaccurate in the area of nutrition. Resident #62's MDS was inaccurate in the area of positioning/mobility. Resident #84's MDS was inaccurate in area of unnecessary medications. Resident identifiers: #96, #14, #9, #95, #62 and #84. Facility census 97. Findings include: a) Resident #96 Resident #96 was admitted to the facility on [DATE] from an acute care hospital due to multiple falls at home. Resident's [DIAGNOSES REDACTED]. Further review of nurse's notes found on [DATE] at 8:05 am, the resident was found unresponsive. Cardiopulmonary resuscitation was initiated due to resident's wishes to be Full Code. Resident #96 was transported to local hospital and expired at the hospital. Review of the MDS with an assessment reference date (ARD) of [DATE] was marked, Death in Facility. During the review of the attending physician's discharge summary found: Patient died at (Name of local hospital. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 3:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Discharge with assessment return not anticipated. b)Resident #14 Medical record review found a Wound Assessment-Pressure Ulcer Assessment, dated [DATE] read: Right and left buttocks, 9.6 centimeters (cm) in length, 9 cm in width and 0.1 cm in depth, stage II. Area less red and not as firm, now with three (3) open areas. Further review found a MDS with ARD of [DATE], was noted Resident #14 had two (2) Stage II pressure ulcers present. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 1:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Three (3) Stage II pressure ulcers . c) Resident #9 Resident #9's medical records indicated she experienced a fall from her bed on [DATE]. Resident #9 had a quarterly Minimum Data Set (MDS) completed with Assessment Reference Date (ARD) [DATE]. Resident #9 also had a MDS completed with ARD [DATE]. Section J, Health Conditions, indicated she had experienced no falls since the prior assessment. During an interview on [DATE] at 12:06 PM, Registered Nurse Assessment Coordinator (RNAC) #127 stated Resident #9's MDS with ARD [DATE], Section J, Health Conditions, should have indicated the resident experienced one (1) fall since the prior assessment. d) Resident #395 During an interview on [DATE] at 11:33 AM, Resident #395 stated she had lost weight recently and was concerned about the weight loss. She said she used to weigh 214 pounds and her weight had decreased to the 170s during her stay at the facility. Resident #395's weight records, Nutritional Risk Notes, and Minimum Data Set (MDS) assessments were reviewed. A quarterly MDS assessment with an Assessment Reference Date (ARD) of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. When determining significant weight loss in section K of the MDS, the RAI manual instructs, Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. The current weight entered in Section K was 182 pounds. This weight (rounded per RAI manual instructions) was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE] and was 208 pounds (rounded per RAI manual instructions). A decrease from 208 pounds to 182 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by the facility's Dietary Services Supervisor (DSS) #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on Section K of the MDS for the ARD of [DATE]. A discharge MDS assessment for Resident #395 with an ARD of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. The current weight entered in Section K was 178 pounds. This weight was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE], per Resident #395's weight records and was 203 pounds (rounded per RAI manual instructions). A decrease from 203 pounds to 178 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by DSS #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on the discharge MDS with an ARD of [DATE]. On [DATE] at 10:44 AM, DSS #122 was asked why she did not code either MDS assessment for significant weight loss over six (6) months when she had marked on her Nutritional Risk Notes that Resident #395 had 10% or Greater Loss using the same two (2) current weight values. She stated that the Nutritional Risk Notes did not correspond with the MDS assessments. She stated that although there was significant weight loss in a timeframe close to 180 days, she did not code this on the MDS because the current weight and comparison weight on each MDS were not exactly 180 days apart. She said she had received an email from The Centers for Medicare and Medicaid Services (CMS) telling her that the RAI Manual had changed and she was to code significant weight loss only if it occurred exactly 180 days preceding the current weight entered in Section K of the MDS. She did not locate or provide a copy of this email for review before the end of the survey. During a phone interview on [DATE] at 12:16 PM, Corporate Registered Dietitian (RD) #133 confirmed that company policy dictates that significant weight loss over a time period of 180 days could only be coded on the MDS if the weight loss occurred at exactly 180 days preceding the current weight marked on the MDS Section K. She added that the policy was developed because there was no clarification in the RAI manual of what the word closest meant in the instructions to use the weight closest to 180 days ago. On [DATE] at 4:04 PM, the definition of close was located in Merriam-Webster's online dictionary. The word close, an adjective, means having little space between items or units or being near in time, space, effect, or degree, according to the dictionary entry. On [DATE] at 10:42 AM, the facility's Director of Nursing was informed of the issue. No further information was provided by the facility prior to the end of the survey. e) Resident #62 Observation of the resident at 1:54 PM on [DATE] found the resident appeared to have limited use of her hands and shoulders. Review of the resident's most recent Minimum Data Set (MDS), a annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures and having full use of her right dominant side. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47 said the MDS was incorrectly coded. RNAC #47 said the MDS should be coded as the resident has limitations of her dominant right side. f) Resident #84 On [DATE], the resident was seen by the nurse practioner (NP). The NP prescribed [MEDICATION NAME], an antidepressant, for a [DIAGNOSES REDACTED]. Review of the residents admission Minimum Data Set (MDS) was a Assessment Reference Date (ARD) of [DATE], found the MDS was not coded to reflect the residents [DIAGNOSES REDACTED]. At 3:42 PM on [DATE], the Registered Nurse Corporate Coordinator, [NAME] #135, confirmed the care plan was incorrectly coded. | 2020-09-01 |
| 534 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 656 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop/and or implement care plans for 4 of 23 residents whose care plans were reviewed. Resident #44's care plan was not developed to include how the facility would provide care to a Dementia resident. Resident #45's care plan was not was implemented for Dementia care. Residents #6 and #70's care plans were not implemented to anchor catheters. Resident identifiers: #44, #45, #6, and #70. Facility census: 97. Findings include: a) Resident #44 Review of the current care plan, revised on 07/20/17, found the problem: (Name of Resident ) has impaired cognitive function related to Dementia. The goal associated with the problem was: Patient will maintain current level of cognitive function through the review date. Interventions included: Administer Meds ([MEDICATION NAME]) as ordered Document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Engage patient in simple, structured activities that avoid overly demanding tasks. A second care plan problem addressed the resident was receiving [MEDICATION NAME] for delusions and hallucinations. The goal of this care plan was: The resident will be/remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions From the guidance to surveyors: Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual's abilities and challenges related to their condition. Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships. People living with dementia may lose their ability to communicate, solve problems, and cope with stressors. They may also experience fear, confusion, sadness, and agitation. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. The physician documented the reason for starting [MEDICATION NAME] as, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. At 9:15 on 11/29/18, the care plan was discussed with the director of nursing (DON). The DON was unable to provide evidence the care plan addressed interventions as to how the staff were to provide care when the resident was delusional. The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime for behaviors. Review of the current care plan, updated on 04/25/18, found the following problems related to the resident's behaviors: (Name of Resident) is verbally abusive and physically aggressive behaviors toward staff while providing care related to ineffective coping skills. The goal was the patient will demonstrate effective coping skills, as evidenced by not being verbally abusive to staff while providing care through next review date. Interventions included: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system. Anticipate patients needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess patients understanding of the situation. Allow time for the patient to express self and feelings towards the situation. When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. A second care plan problem, updated on 01/29/18 found: (Name of Resident) has a behavioral problem related to yelling for help instead of utilizing the call bell system for needs and assistance. Resident will hit at staff while providing care. The goal associated with the problem was: The resident will have fewer episodes of yelling for help instead of utilizing the call bell system for requesting her needs. Interventions included: Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. At 11/28/18 at 02:41 PM, the director of nursing confirmed she was unable to provide information to substantiate the above approaches were implemented as directed by the care plan. The DON confirmed the interventions were in place before the antipsychotic medication was started. The DON further confirmed the non-pharmacological interventions were not implemented before starting the antipsychotic medication. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided. e) Resident #70 On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor (used to prevent injury and accidental removal) was not on the resident's leg. Both NA #40 and NA #85 agreed that the anchor was not there and should be on the leg. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. - Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. | 2020-09-01 |
| 535 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 657 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans when residents had changes in their care related to advance directives, position and mobility, and [MEDICAL TREATMENT] schedule. This was found to be true for three (3) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #395, #62, #16. Facility census: 97. Findings included: a) Resident #395 On [DATE] at 1:32 PM it was noted through the screening portion of the Long-Term Care Survey Process that the code status marked on Resident #395's profile in the electronic medical record did not match the code status indicated on the care plan. The code status on the profile in the electronic medical record stated, Resuscitate (CPR); Feeding Tube Long-Term; Patient has a completed POST form dated: [DATE]; Limited Additional Interventions; IV Fluids for a trial period of no longer than: ,[DATE] days. A review of the current Physician order [REDACTED].#395's representative on [DATE], stated to Attempt Resuscitation/CPR and to provide Limited Additional Interventions, IV fluids for a trial period of no longer than ,[DATE]d(ays), and Feeding tube long-term. A previous POST form, signed by Resident #395's representative on [DATE], indicated to provide full interventions as well as IV fluids for a trial period of no longer than ,[DATE]d(ays). It was marked VOID. Resident #395's physician orders [REDACTED]. However, the advance directives documented on the care plan stated, Full interventions, IV fluids for a trial period of no longer than ,[DATE] days, Feeding tube long term. According to date stamps on the care plan, this information was last revised on [DATE] by Registered Nurse Assessment Coordinator (RNAC) #47. During an interview on [DATE] at 2:20 PM, RNAC #47 acknowledged that the advance directive information on the POST form and the care plan did not match and stated she would fix the problem immediately. On [DATE] at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided by the facility prior to the end of the survey. b) Resident #62 Review of the resident current care plan, revised on [DATE], found the following problem: (Name of Resident) has an ADL (activities of daily living) self care performance deficit related to altered mental status,[MEDICAL CONDITION], dementia, [MEDICAL CONDITIONS], contracture to left arm and hand and [MEDICAL CONDITION]. Review of the most recent minimum data set (MDS) an annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47, said the care plan was incorrect. The RNAC noted the resident had contractures when she was admitted to the facility on [DATE]. When the contractures resolved the care plan was never updated to reflect the resident currently has no contractures to the left arm and hand. c) Resident #16 A reviewed of Resident #16's medical record at 9:26 a.m. on [DATE] found the following physician order [REDACTED]. A review of Resident #16's care plan found the following focus statement, : [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. This focus statement was added to the care plan on [DATE]. The goal associated with this focus statement read, : Will have no signs or symptoms complications fro [MEDICAL TREATMENT] through the review date. The revision date for this goal was [DATE] with a target date of [DATE]. The goals associated with this focus statement and goal included, Encourage patient to go for the scheduled [MEDICAL TREATMENT] appointments. Patient receives [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays at 6:15 a.m. at (Name of local [MEDICAL TREATMENT] center) . This intervention was added to the care plan on [DATE]. An interview with Registered Nurse Assessment Coordinator (RNAC) #47, at 9:56 a.m. on [DATE] confirmed Resident #16's care plan was not revised when her [MEDICAL TREATMENT] days and times changed on [DATE] at it should have been. | 2020-09-01 |
| 536 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 660 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a plan was in place to address the the residents expressed desire to talk to someone about in-home and community agencies available before her discharge to home. This was true for one (1) resident reviewed for the care area of discharge to the community. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 Record review at 9:20 AM on 11/27/18, found the resident was admitted to the facility on [DATE]. The resident was discharged to her home on 08/31/18. Review of the minimum data set (MDS), a 5 day Medicare Part A Stay, with an assessment reference date (ARD) of 06/19/18, found the resident participated in completing the MDS. The resident expected to be discharged to the community. When asked the question on the MDS, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The residents response was, yes. The Resident Assessment Instrument (RAI) manual provides the following direction when answering yes to the above question on the MDS: The goal of follow-up action is to initiate and maintain collaboration between the nursing home and the local contact agency to support the resident's expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. This includes the nursing home supporting the resident in achieving his or her highest level of functioning and the local contact agency providing informed choices for community living and assisting the resident in transitioning to community living if it is the resident's desire. The underlying intention of the return to the community item is to insure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive setting. CMS (Centers for Medicare and Medicaid Services) has found that in many cases individuals requiring long term services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. Local contact agencies (LCAs) are experts in available home and community-based service (HCBS) and can provide both the resident and the facility with valuable information. On 11/27/18 at 10:06 AM, the social worker (SW) #28 was asked for verification of information provided to the resident about all community based services and support systems. There were no notes in the electronic medical record from social services discussing discharge placement. SW #28 said referrals for medical equipment were made and the resident was referred to a Home Health agency before discharge. He was unable to provide any documentation a discussion was held with the resident to determine what other agencies were available in her community. Such as agencies who provide meals, chore services, transportation, and other in-home care and community based services that could be available. On 11/27/18 at 10:17 AM, the supervisor of therapy services, Employee #118, said the therapists recommended the equipment needed at home. We always refer residents to a Home Health agency upon discharge, for a safe transition to the community. [NAME] #118 said her department does not look at other agencies available in the community, That is Social Services. At 10:40 AM on 11/27/18, a visiting social worker, from another company facility, SW #134 said, We will get some training in place to address this. | 2020-09-01 |
| 537 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 684 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, resident interview, and the National Pressure Ulcer Advisory Panel's (NPUAP), the facility failed to provide quality treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This was true for six (6) of twenty-three (23) residents reviewed. For Residents #37, #14, #345, and #9 had wounds not assess, monitor and treat wounds as indicated. Resident #43 did not have a follow appointment as directed by the discharging physician. Additionally, Resident #59's bowel and bladder incontinence was not accurately assessed. Resident identifiers: #37, #14, #345, #9, #43, and #59. Facility census: 97. Findings include: a) Resident #37 Medical record review found Resident #37 was admitted to the facility on [DATE]. Additionally, Resident #37 had a facility acquired pressure ulcer to the Matrix. Review of Resident #37 nursing assessment and wound assessments: Nursing assessments for 01/09/18, 04/10/18, and 04/10/18- No pressure ulcers noted. --10/02/18- Initial wound assessment dated [DATE]: coccyx- Stage II- measured 0.9 centimeter (cm) in length (l) and 0.6 cm in width (w) and 0.1 cm depth (d). --10/05/18 - Nursing assessment- Coccyx- dressing intact, see detailed initial pressure ulcer assessment (dated 10/02/18). Right inner foot - see detailed non-pressure wound evaluation. (None could be found). --10/08/18- Coccyx- Stage II- measured 0.8 cm l and 0.4 cm w. and 0.1 cm in depth. --10/09/18-Initial assessment-right inner heel- Stage II- blister which had ruptured and measured 3.0 cm in l and 3.5 cm in w and 0.1 cm in d. --10/17/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel Stage II- measured 2.2 cm l and 3.0 cm w. and 0.1 cm in depth --10/24/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel- Unstageable- measured 1.0 cm l and 1.5 cm w. and unknown depth-area with da ark red scab surrounding area red and blanches --10/31/18- coccyx- stage II- area closed right heel Unstageable- area with dark red scab surrounding area red and blanches. measured 1.0 cm l and 1.5 cm w. and depth unknown. --11/05/18- Initial Assessment- left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1.5 cm width and unknown depth. Wound bed is dark purple in color --11/07/18- coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and width and unknown depth. Wound bed is dark purple in color --11/14/18- right inner heel Unstageable- area with dark red scab surrounding area red and blanches measured 2.0 cm l and 2.0 cm w. and unknown in depth. --11/15/18- coccyx- stage II- area closed no redness noted. left trochanter (hip) - area closed red but blanches. --11/21/18- coccyx Suspected deep tissue injury- area 8 cm in length and 6 cm in width and unable to determine. right inner heel Unstageable- area with dark red scab surrounding area red and blanches --11/22/18- Initial assessment: Left heel- blister measured 3 cm x 3 cm unstageable. coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1 cm in width and unknown depth. Wound bed is dark purple in color. b) Resident #14 Review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Further review found the following nursing assessments and wound assessments found: --Initial wound assessment -07/10/18- right buttock- Stage 2- measured 1.5 cm in l and 1.0 cm w and 0.1 cm in d. Follow wound assessments: --7/17/18- right buttocks - Stage 2- measured 2.0 cm in l and 2.0 cm w and 0.1 cm in d. --7/24/18- right buttock- Stage 2- measured 2.0 cm in l and 1.4 cm w and 0.1 cm in d. --7/31/18- right buttock- Stage 2- measured 2.0 cm in l and 1.3 cm w and 0.1 cm in d. --8/7/18- right buttock- Stage 2- measured 2.8 cm in l and 1.2 cm w and 0.1 cm in d. --8/14/18- right buttock- Stage 2- measured 2.0 cm in l and 1.0 cm w and 0.1 cm in d. --8/21/18- right buttock- Stage 2- measured 2.0 cm in l and 1.2 cm w and 0.1 cm in d. --08/28/18- right/left buttocks- Stage 2- measured 13.0 cm in l and 11.0 cm w and 0.1 cm in d. Additional notes: Area has now spread to left buttock, entire area is dark red/purple, warm to touch and does not blanche. Has multiple open areas varying in sizes, complaint of itching, bowel movements are now soft and formed, allows staff to turn more frequently, fluid intake fair. Wound care provided. --8/31/18-Nursing assessment: Stage II - sacrum- measured 13.0 cm in l x 11.0 cm in w. Multiple areas draining small amount of bright red fluid draining , no odor present. Stage II observed to sacral area- skin warm dark red/purple, non-blanchable, multiple open areas, small amount of bright red drainage present. --9/4/18- right and left buttocks- Stage II- measured 10.2 cm in l and 10.5 cm in l and 0.1 cm in d. four (4) open areas remain. --09/12/18- right and left buttocks- Stage II - measured 9.6 cm in l and 9.0 cm in l and 0.1 cm in d. three (3) open areas. --09/12/18- Nursing Assessment- right buttock and left buttock- Both reads: Unable to observe due to bordered foam dressing. No drainage or odor noted. --09/18/18- #1) coccyx - Stage II Stage II- measured 3.7 cm in l and 2.5 cm in l and 0.1 cm in d. - Area was being measured as one big area, but now open in multiple areas. Scant amount of bloody drainage observed, no odor observed. #2) - right buttock- Stage II-- measured 1.0 cm in l and 0.5 cm in l and 0.1 cm in d #3) left buttock- Stage II- measured 2.0 cm in l and 0.8 cm in l and 0.1 cm in d. --9/25/18 #1- coccyx- Stage II- measured 3.7 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 2.0 cm in l and 0.7 cm in l and 0.1 cm in d. #3- right buttock- Stage II- measured 0.8 cm in l and 0.5 cm in l and 0.1 cm in d. --10/02/18- #1- coccyx- Stage II- measured 3.0 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.4 cm in l and 0.4 cm in l and 0.1 cm in d. --10/09/18- #1- coccyx- Stage II- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.3 cm in l and 0.3 cm in l and 0.3 cm in d. --10/16/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Stage II- measured 0.5 cm in l and 0.5 cm in l and 0.1 cm in d. --10/23/18- #1- coccyx- Stage III- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.5 cm in l and 0.5 cm in l and unknown d. --10/31/18- #1- coccyx- Stage III- measured 3.4 cm in l and 1.3 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.4 cm in l and 0.4 cm in l and unknown d. --11/06/18- #1- coccyx- Stage III- measured 3.0 cm in l and 1.0 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.2 cm in l and 0.3 cm in l and unknown d. --11/13/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.0 cm in l and 0.1 cm in d. #2- right buttock- Healed. --11/27/18- #1- coccyx- Stage III- measured 2.8 cm in l and 1.0 cm in l and 0.1 cm in d. The updated staging system developed by the National Pressure Ulcer Advisory Panel (NPUAP) includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage IV. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 11/28/18 at 3:30 pm confirmed the nursing assessments and the wound sheets were not consist and accurate in type of wound, staging and location. they confirmed they had identified the inconsistency. c) Resident #9 Resident #9 was interviewed on 11/26/18 at 10:52 AM. She was noted to have a 4x4 secured with tape on the front of her right lower leg. Resident #9 stated she also had an open area on the back of her right lower leg. She stated she had completed a course of antibiotics for [MEDICAL CONDITION] but continued to have weeping of fluid from her leg requiring a dressing. Review of Resident #9's medical records revealed she had a [DIAGNOSES REDACTED]. There was no documentation of the application of a dressing to Resident #9's right lower leg. There were no physician orders regarding the application of a dressing to Resident #9's right lower leg. On 11/28/18 at 1:46 PM, Resident #9 was observed in her wheelchair in the hallway outside her room. She stated she did not have a dressing on her right lower leg at that time. She stated she was waiting for a nurse to look at it because she had been having drainage from her leg. While surveyor was speaking to Resident #9, Licensed Practical Nurse (LPN) #108 took Resident #9 into her room to assess her right lower leg. LPN #108 stated Resident #9 had an open area on the back of her right lower leg. LPN #108 stated she would have the unit's Clinical Care Supervisor (CCS) assess the area. On 11/28/18 at 2:35 PM, Resident #9 was observed in the hallway in her wheelchair. She had a dressing on her right lower leg. A wound assessment written by LPN #108 11/28/18 at 2:03 PM stated, An evaluation of this patient's wound was completed by this nurse. Wound location is: Posterior RLE (right lower extremity). Interventions for treatment and healing of this wound are contained in the patient's physician orders and interdisciplinary plan of care. Monitoring and re-evaluation of this wound will be on-going. A wound evaluation- non-pressure wound assessment was completed by LPN #108 on 11/28/18 at 2:03 PM. The wound evaluation stated, Resident c/o (complained of) sock feeling wet. UCN (unit charge nurse) assessed area. RLE with weeping vascular area that measures 1.5x 1cm x less than 0.1 cm. Area is moist and pinkish white in color. Active clear drainage noted. No odor noted. Resident does have [MEDICAL CONDITION] to BLE. (Physician's name) notified. New orders to cleanse area with skin-tegrity pat dry, apply ABD (abdominal) pad and cover with kling. Resident is not a candidate for increase in diuretics due to renal function. AMA (against medical advice) on file for refusals of ace wraps to BLE (bilateral lower extremity) and is also non-compliant with that at times. Resident aware of above. A physician's order written on 11/28/18 at 2:08 PM stated, Cleanse vascular area to RLE with skin-tegrity, pat dry, apply ABD pad and cover with kling every shift for weeping vascular area. During an interview on 11/28/18 at 3:30 PM, CCS #19 stated she had no information regarding when the right lower leg dressing observed on Resident #9 on 11/26/18 had been applied or who applied the dressing. CCS #19 was unable to locate any previous documentation regarding this dressing or a prior assessment of Resident #9's right lower leg skin condition. She stated Resident #9's leg was assessed today and a wound care order was obtained from the physician. CCS #19 stated the physician would assess the resident's leg. d) Resident #43 On 09/17/18, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. Resident #43 was discharged from the hospital on [DATE]. The discharge summary provided by the hospital to the facility gave the plan as follows (typed as written): - Discharge back to nurse or not rehab - Resume home medications - Follow up with her regular cardiologist within the next 1-2 weeks - See PCP (primary care provider) within the week - Return if worsening concerns. Review of the medical records did not show evidence Resident #43 had seen a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. On 11/07/18, Resident #43 returned to the hospital due to shortness of breath. During an interview on 11/27/18 at 12:20 PM, the Director of Nursing (DoN) was asked if an appointment with Resident #43's cardiologist had been made when she returned to the facility on [DATE] as was recommended by the discharging physician. During an interview on 11/28/18 at 9:44 AM, the DoN confirmed Resident #43 did not see a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. The DoN stated on 11/27/18 an appointment with a cardiologist had been made for 12/12/18. e) Resident #345 On 11/26/18 at 11:13 AM, it was noted Resident #345 had an opened wound without any dressing on the bottom of his left foot. During an interview on11/27/18 at 9:31 AM, Licensed Practical Nurse (LPN) #23 looking for current notes about wound on foot. After looking at his foot which it appeared to be dry with a thick callus, an area that appeared to have a hole estimating 3.5 centimeters (cm) by 4 cm, with a yellowish colored layer dipping down. She said that he had this on return to the facility but could not recall when that was. During an interview on 11/27/18 at 12:00 PM, asked DoN about wound care and documentation for the wound on the left foot. It was pointed out to her that the documentation was incomplete and inconsonant. She stated that she would look to see if she can more documentation. During an interview on 11/29/18 at 8:38 AM, Administrator was asked about the wound on the left foot of Resident #345. She was asked if she could follow the skin evaluations and the wound assessments? She stated she aware of the poor documentation and is working on that currently. She agreed that the documentation did not paint a clear picture of his wound and the changes concerning the wound. Review of the medical chart revealed that the Skin Evaluation dates started 1/04/18 thru 08/28/18 never had a statement about the wound on the left foot. On the Wound Assessment portion, the first time it was documented was on 04/09/18. On 05/03/18 was the first time it was documented in the Wound Document portion. On 9/13/18 was the first time any nurse had documented any measurements. Review of the Infections Nursing Notes Portion revealed an infection to the left foot on two (2) separate occasions 05/16/18 thru 05/22/18 he received an antibiotic and then again from 08/21/18/to 08/30/18. At this time on 08/21/18 a culture and sensitivity were obtained. A review of the medical records revealed the Nurses were referring to this wound an avulsion (is when skin is pulled off). The Physician who was treating the foot referred to the wound as an ulcer. The Care Plan referred to the wound as a diabetic ulcer. Resident #345 has the following medical Diagnosis: [REDACTED]. f) Resident #59 Review of the residents minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 10/22/18, found the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. Review of the last nursing assessment, dated 10/18/18, found the resident was coded as using the toilet or bedpan and having no episodes of incontinence of urine or bowel. At 9:54 AM on 11/28/18, the Registered Nurse Assessment Coordinator (RNAC) #47, said the nursing assessment was incorrect. RN #47 provided documentation from the nursing assistants to verify the MDS was correct and the nursing assessment was incorrect. RNAC #47 said the nursing assessment should have coded the resident as having episodes of incontinence of both urine and bowel. At 11:56 AM on 11/28/18, the director of nursing (DON) confirmed the nursing assessment was incorrect. On 11/28/18 at 3:18 PM, the documentation on the nursing assessment and the MDS was discussed with the administrator and the vice president of quality care, [NAME] #136. No further information was provided before the close of the survey at 12:15 PM on 11/30/18. | 2020-09-01 |
| 538 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 690 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure residents, with an indwelling catheter, received the appropriate care based upon current professional standards of practice and services to prevent urinary tract infections to the extent possible. Also failed to ensure the indwelling Foley catheter was secured to the leg was used to prevent injury, accidental removal. This was true for two (2) of two (2) reviewed for catheter care. Identified Residents were Resident #70 and #6. Facility Census 97. Findings included: a) Resident #70 During an interview on 11/26/18 at 11:39 AM, Resident's husband said that she has ESBL in urine she has a catheter. On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor was not on the resident's leg. NA#40 wiped once down the sides of the inner legs (groin area), one down stroke over the outside of the vagina. She then emptied the water basin and left room. When she returned with clean wash cloth and water she wiped the catheter tubing but not at the insertion site, only a section of the tubing about 3 inches from the vagina. Licensed Practical Nurse (LPN) #27 brought in a thigh strip to secure the Foley catheter to the leg. NA #85 wiped the buttock crevices toward the vagina, not away from the vagina to prevent Infections. After the two (2) NAs had finished and put the supplies away they were asked the following; - How often are they in-serviced on catheter care? They both said the last time was in (MONTH) this year. - How do they believe they did? NA # 85 said that, she knew that she should not have wiped towards the vagina and NA #40 said she normally does a better job. Both NAs agreed they did not use proper technic for catheter care. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) - report unsecured catheters to the Charge Nurse. The Facility Policy, Perineal Care Dated, 1,2002, reads: -Wash perineal area wiping from front to back. -Separate labia and wash area downward from front to back - gently wash the juncture of the tubing from the urethra down. -Continue to wash the perineum moving from inside outward to and including the thighs alternating from side to side and using downward [MEDICAL CONDITION]. Do not use the same washcloth or water to clean the urethra or labia. -Wash the rectal area thoroughly, wiping the base of the labia towards and extending over the buttocks, do not use the same washcloth or water to clean the labia. Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. b) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided. | 2020-09-01 |
| 539 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 698 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #16 a [MEDICAL TREATMENT] patient received care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #16 reported that she is late to [MEDICAL TREATMENT] frequently because the ambulance is always late to get her. Also, Resident #16 had an order for [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 1. Transportation to [MEDICAL TREATMENT] During an interview with Resident #16 at 12:00 p.m. on 11/26/18, she stated, I am late for [MEDICAL TREATMENT] on a regular basis. She indicated her appointment was set for 12:00 p.m. and the ambulance often times picked her up after her scheduled appointment time. She stated, I am supposed to be on the machine all ready and I am still sitting her waiting for them to come and get me. She stated, This happens at least once or twice a week. At 12:16 p.m. on 11/26/18, the ambulance company was observed arriving to pick up resident #16 for her [MEDICAL TREATMENT] appointment which was scheduled at 12:00 p.m. A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found the following physician order [REDACTED].>Further review of the record found the following dates which Resident #16 was picked up for her [MEDICAL TREATMENT] appointment after her scheduled appointment time: All notes are entered by nursing and are appointment/outing notes. The times used are the effective times of the note which would be the time Resident #16 left the building in route to her [MEDICAL TREATMENT] treatment: 07/18/18 at 12:45 p.m. 08/01/18 at 12:55 p.m. 08/27/18 at 12:03 p.m. 09/04/18 at 1:32 p.m. 09/14/18 at 12:19 p.m. 09/24/18 at 12:51 p.m. 09/28/18 at 12:02 p.m. 10/08/18 at 12:10 p.m. 11/02/18 at 12:04 p.m. 11/12/18 at 12:47 p.m. 11/26/18 at 12:15 p.m. 11/29/18 at 12:03 p.m. An interview with the local [MEDICAL TREATMENT] center staff at 10:09 a.m. on 11/28/18 confirmed Resident #16 as consistently late to [MEDICAL TREATMENT]. She stated, She is late at least once or twice a week and it puts us behind for the rest of the day. An interview with the Director of Nursing (DON) at 11:47 a.m. on 11/28/18 confirmed the nursing notes indicated Resident #16 was picked up late for [MEDICAL TREATMENT] on the dates mentioned above. She stated they would have to address it with the ambulance company because this is the first she has heard of it. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 found she had spoken with the ambulance company and they stated they would try to do better picking up the resident on time. 2. [MEDICATION NAME] A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered. | 2020-09-01 |
| 540 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 744 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents diagnosed with [REDACTED]. This was true for three (3) of three (3) residents reviewed for the care area of Dementia. Resident identifiers: #44, #45, and #92. Facility census: 97. Findings include: a) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. | 2020-09-01 |
| 541 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 757 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #16's drug regimen was free from unnecessary medications. Resident #16's [MEDICATION NAME] was ordered to be held at certain times on [MEDICAL TREATMENT] days and it was not held as ordered. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered. | 2020-09-01 |
| 542 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 758 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents where not placed on [MEDICAL CONDITION] medication before the facility utilized individualized non-pharmacological approaches to care. Therefore these residents medication could not be proven to necessary. This was true for four (4) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident identifiers: #92, #45, #44, and #84. Facility census: 97. Findings Include: a) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and any non pharmacological interventions they had put into place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. She also confirmed there was no documented non pharmacological interventions in the medical record prior to starting Resident #92 on [MEDICATION NAME]. b) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. c) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. d) Resident #84 Record review found a seventy eight year old female admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED] The resident was admitted with the [MEDICAL CONDITION] medication, [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg's every 4 hours for anxiety. The [MEDICATION NAME] was discontinued on 11/03/18. A new order for [MEDICATION NAME] was written on 11/03/18 for [MEDICATION NAME] .25 mg's every 8 hours for anxiety. This order was discontinued on 11/04/18. On 11/05/18 another order was written for [MEDICATION NAME] .5 mg's three times a day for anxiety. This order was discontinued on 11/05/17. On 11/05/17, a new order was written for [MEDICATION NAME] .25 mg's three times a day for anxiety. This order was discontinued on 11/06/18. On 11/06/18 another new order was written for [MEDICATION NAME] .25 mg's two times (BID) a day. (The resident is currently receiving [MEDICATION NAME] .25 mg's BID. On 11/06/18 the physician saw the resident at the facility. According to documentation from the physician, the resident told the physician, .she feels like she is very drugged. States, I think I'm getting too much [MEDICATION NAME]. The physician decreased the [MEDICATION NAME] to .25 mg's two times a day. On 11/06/18 the physician also ordered [MEDICATION NAME] 5 mg's daily. On 11/27/18 at 2:00 PM, the Registered Nurse corporate coordinator, RN #135 was asked why the resident was started on the [MEDICATION NAME]? On 11/27/18 at 3:07 PM, RN #135 said she did not know why the physician started the [MEDICATION NAME]. RN #135 was unable to provide documentation of any resident behaviors and unable to provide documentation of any non-pharmacological interventions provided before starting the [MEDICATION NAME]. RN #135 was unable to find documentation as to why the [MEDICATION NAME] orders were changed on five occasions during a 6 day time frame. RN #135 found documentation the resident was complaining of feeling real shaky on the inside and nervous on 11/05/18, so the physician, started her [MEDICATION NAME] back. However, review of the MAR found the resident received [MEDICATION NAME] .25 mg's at 2:00 PM and 10:00 PM. The resident also received [MEDICATION NAME] .5 mg's at 2:00 PM. The [MEDICATION NAME] was not discontinued on 11/05/18-only the dosage was changed. As the orders are entered into the computer electronically and approved electronically by the physician there is no way to determine if the physician's orders [REDACTED]. At the close of the survey on 11/29/18 at 12:15 PM, no further information was provided to verify the resident received non-pharmacological interventions before starting the antidepressant, [MEDICATION NAME]. Also there was not documentation provided to substantiate the resident was exhibiting behaviors indicating she was depressed and required an anti-depressant medication. | 2020-09-01 |
| 543 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 812 | F | 0 | 1 | J9FW11 | Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner. Bowls and tray covers were not stored inverted and foods that had passed their use by/best by/expiration dates were found in a refrigerator, a food serving area, and the dry storage area. This had the potential to affect all residents in the facility. Facility census: 97. Findings included: a) Kitchen Tour An initial tour of the facility kitchen began on 11/26/18 at 10:23 AM with Dietary Services Supervisor (DSS) #122. During this tour, one (1) individual bowl of prepared salad with a use by date of 11/22/18 was found in a refrigerator containing resident food across from the tray line. DSS #122 removed the salad at the time of the finding. On shelves underneath the tray line, a box labeled Orange Pekoe and Pekoe Cut Black Tea containing 41 loose tea bags was found to have a best by date of 07/12/15. On the same shelves underneath the tray line, stacks of bowls were found facing up, potentially exposing the insides of the bowls to dust, debris, and/or splatter. Numerous tray covers were found on top of the tray line also facing up, potentially exposing the insides to dust, debris, and/or splatters. Once notified of the above issues, DSS #122 removed the box of loose tea bags. She stated that she did not feel that the bowls and tray covers needed to be stored inverted since they were dry. DSS #122 confirmed that the bowls and tray covers were used in serving resident food. She was then asked for a facility policy indicating that it was acceptable not to invert bowls and tray covers to be used in serving resident food. DSS #122 stated she was not aware of any such policy. In the dry storage room, 11 more boxes of Orange Pekoe and Pekoe Cut Black Tea were found. Each box had a best by date of (MONTH) (YEAR) and contained 100 tea bags. One (1) 11-pound container of vanilla creme icing with a use by date of 11/10/18 was also found in the dry storage area. At 10:37 AM, DSS #122 was notified of the findings and removed the outdated items from storage. On 11/29/18 at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issues. No further information was provided by the facility prior to the end of the survey. | 2020-09-01 |
| 544 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 865 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies which it did have or should have had knowledge of. The facility failed to identify the fact that three (3) of three (3) residents reviewed for the care area of dementia management was started on antipsychotic medications when no non pharmacological interventions and been put in place prior to the starting of the medication. This practice has the potential to effect more than an isolated number of residents currently residing in the facility. Resident Identifiers: #92, #44, and #45 Facility Census: 97. Findings Include: a) Treatment/Services for Dementia 1. Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. 2. Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. 3. Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. b) QA and A interviews. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at 9:57 a.m. on 11/29/18 confirmed they reviewed antipsychotic medications in the QA and A when they meet monthly. They indicated they had identified they had some issues with documentation of behaviors and non pharmacological interventions but they had not implemented a plan to correct the identified issues. The medications in question were started as early and 06/01/18 and the QA and A committee had numerous months to initiate a plan for improvement, but had failed to do so. and staging was not consistent. | 2020-09-01 |
| 3271 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 157 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of seventeen (17) residents reviewed, experienced changes in medical conditions. The responsible party was not notified when Resident #86 experienced a fall at the facility, and when changes to medication were made due to an irregular laboratory value. Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. . | 2020-09-01 |
| 3272 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 164 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility provided confidential medical information to an entity who was not the resident's responsible party. This was true for one (1) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. . | 2020-09-01 |
| 3273 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 241 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to carry out activities to assist the resident to maintain his self-esteem and self -worth. This was true for one (1) of one (1)resident reviewed for the care area of dignity. Resident #29 had a persistent urine odor. Resident identifier: #29. Facility census: 58. Findings include: a) Resident #29 Observation of the resident in Stage 1 of the Quality Indicator Survey (QIS) at 4:54 p.m. on 02/06/17 found the resident was in his room, in bed and under the covers. Upon entrance to the room, a strong urine odor was detected. The odor was permeating from the area where the resident was located. Review of the resident's current care plan found no information to indicate the resident refused personal care. The care plan addressed the resident's activities of daily living (ADL's) and directed the resident's bathing required the assistance of one (1) staff member for bathing on Tuesday's, Thursday's and Saturday's. Observation of the resident at 9:45 a.m. on 02/08/17, found the odor was still persistent. Review of the resident's shower schedule with Employee #88, the unit secretary, at 10:00 a.m. on 02/08/17, found documentation the resident had received a shower on 02/07/17. At 10:10 a.m. on 02/08/17, Registered Nurse (RN), #8, working on the resident's unit, said the resident usually has a urine odor. She stated sometimes he refuses care. At 10:20 a.m., on 02/08/17, the resident was observed in his bed. The director of nursing (DON) was present for the observation. The DON acknowledged the odor and said it could be his mattress and sometimes the resident hides his briefs. Observation of the room, found no indication the resident had hid his briefs on this day. The DON said she would have the sheets and blankets stripped and his mattress cleaned. She said the facility had recently purchased a new mattress for the resident. She said the resident is known to dribble urine on himself, his bed and the floor of his room. He urinates everywhere. At 10:35 a.m., on 02/08/17, Housekeeper (HSK) #17, was cleaning the resident's room. The resident was not present in his room. HSK #17 acknowledged the urine odor. He and his room just smell like urine. Review of the current minimum data set (MDS) with an assessment reference date (ARD) of 12/25/17, found the resident was always incontinent of bowel and bladder. [DIAGNOSES REDACTED]. The resident was receiving the medications: [REDACTED]. Review of the resident's laboratory values for 02/01/17 found the bun and creatinine were within normal limits, indicating the resident most likely did not have a urinary tract infection. At 6:47 p.m., RN #8 said she has noticed a urine odor in the resident's room. He is incontinent a lot. They pretty much change out the whole bed every day. Observation of the resident by two (2) surveyors at 6:59 p.m. on 02/08/17 found the odor continued to be present in the resident's room. At 7:10 p.m. on 02/08/17, the resident's nurse aide (NA), #38 said, Yeah, the room smells like urine, because he dribbles urine in the room. The nurse surveyor observed incontinence care on the evening of 02/08/2017. At 7:27 p.m. on 02/08/17, the nurse surveyor stated the urine odor, Took my breath, when the brief was removed. Upon entrance to the resident's room at 7:45 p.m. on 02/08/17, the urine odor was only slightly present in the resident's room. At 7:45 p.m., RN #52, said she could find no evidence the resident had seen a urologist since 05/2015. She said the resident was admitted to the facility on [DATE] and there could be more records which she did not have access to review. At 8:05 a.m. on 02/09/17, the DON said, I take offense to you writing that deficiency. We know he has an odor and we work hard to keep him clean. She was asked to provide verification the facility had addressed the urine odor, such as the care plan, nursing notes, urology consults, etc. At 8:30 a.m. on 02/09/17, the DON provided a copy of a urology consult on 05/22/14 ordered for retention of urine and a strong odor. This was the last time the resident has seen the urologist. The DON was unable to read the results of the consult. She said the resident's mattress had been replaced in (MONTH) (YEAR). The resident's physician was interviewed on 02/09/2017 at 9:26 a.m. The physician said, If it has been that long since the urology consult, maybe he needs to go back. At 9:27 a.m. on 02/09/2017, the DON confirmed the care plan did not include the interventions the facility had taken to resolve the odors. The DON was unable to provide further documentation as to how the facility had worked to resolve the urine odor of which they were well aware of. At the close of the survey at 4:45 p.m. on 02/09/17, no further information had been provided. | 2020-09-01 |
| 3274 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 272 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to complete an accurate comprehensive assessment for two (2) of seventeen (17) Stage 2 sampled residents whose comprehensive assessments were reviewed. Resident #42 sustained a fall with injury which was not assessed on her annual comprehensive assessment. Resident #43's comprehensive assessment was incorrect in the areas of falls and prognosis. Resident identifiers: #42 and #43. Facility census: 58. Findings include: a) Resident #42 The medical record was reviewed on 02/08/17. According to nurse progress notes, she sustained a fall with injury on 10/31/16, which consisted of a nickel sized bruise to the right knee, and complaints of pain to that area. Nursing notified the physician of the incident, and received new orders for x-rays of the right knee. Nursing administered a scheduled pain medication at that time. Review of this resident's annual minimum data set (MDS) with assessment reference date (ARD) of 12/15/16, incorrectly assessed this resident sustained [REDACTED]. An interview was conducted with MDS registered nurse #26 on 02/08/17 at 2:00 p.m. After she reviewed the 10/31/16 nursing progress note and the 10/31/16 incident report, she said the resident's annual MDS with ARD 12/15/16 should have assessed she sustained one (1) fall with injury since the previous MDS, and it did not. This information was shared with the director of nursing on 02/09/17 at 1:10 p.m. She provided no further information prior to exit. b) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed an admission date of [DATE]. A significant change MDS, with an assessment reference date (ARD) of 09/10/16, indicated Resident #43 had no falls since admission, entry or reentry or prior assessment, whichever is more recent. Review of Resident #43 incident reports for the period of time since the last MDS and the significant change MDS with ARD of 09/10/16, found Resident #43 had one (1) fall during this period on 08/29/16 at 6:12 a.m., resident was sitting in the bathroom floor, he stated he missed sitting on the commode and he stated he hit the back of his head when he fell . Additionally, a significant change MDS, with an ARD of 11/07/16, indicated Resident #43 had had no falls since admission, entry or reentry or prior assessment, whichever is more recent. Review of Resident #43 incident reports for the period of time since last MDS on 09/10/16 found the resident had six (6) falls: --09/30/16 at 10:22 a.m., Slid from side of bed to floor. No injuries. --10/09/16 at 2:37 a.m., Slid from bed to floor. No injuries. --10/09/16 at 1:30 p.m., Found sitting in the floor beside his bed. Complained of right hip and right wrist pain. --10/13/16 at 7:30 a.m., Slid off the edge of wheelchair in the bathroom. No injuries. --10/19/16 at 2:00 a.m., fell while trying to get to the wheelchair from the bed . No injuries. --10/30/16 at 2:56 p.m., Transferring from bed to wheelchair and slid to floor. No injuries. 2. Prognosis A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed an admission date of [DATE]. A significant change MDS, with an assessment reference date (ARD) of 09/10/16, indicated Resident #43 was receiving hospice care. Review of Resident #43 physician progress notes [REDACTED]. Additionally, a significant change MDS, with an ARD of 11/07/16, indicated Resident #43 did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Further review of the physician progress notes [REDACTED]. 3. Interview During an interview on 02/09/17 at 9:15 a.m., MDS Coordinator #24 said Resident #43 had one (1) fall on 08/29/16 and should have been noted on the significant change MDS with ARD of 09/10/16 and his hospice services had ended on 08/28/16. Additionally she said the resident had six (6) falls from 09/10/16 through 11/07/16 as previously documented and should have been placed on the significant change MDS with ARD of 11/07/16 and the resident had had a decline and was restarted on hospice services on 10/24/16. The MDS Coordinator confirmed the MDS with an ARD of 09/10/16 and MDS with ARD of 11/07/16 were inaccurate in the areas of falls and hospice/prognosis. | 2020-09-01 |
| 3275 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 278 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete Resident #43's quarterly Minimum Data Set (MDS), in the areas of prognosis and falls. Resident #51's thirty (30) day MDS was inaccurate in the area of weight loss. This was true for two (2) of seventeen (17) Stage 2 residents MDS's reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #43 and #51. Facility census: 58. Findings include: a) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 had one (1) fall since the prior assessment. Review of Resident #43's incident reports for the period of time since the last MDS, found Resident #43 had three (3) fall during this period: --On 11/09/16 at 11:30 a.m., Leaned over from his wheelchair to pick something up from the floor and fell to the floor. No injuries. --On 01/05/17 at 2:15 a.m., fell when attempting to get out of bed to check on his wife (roommate). No injuries noted. --On 01/05/17 at 9:00 a.m., Slid out of bed to floor. Resident had a lump on right side of forehead and complained of knee pain. 2. Prognosis Further review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 did not have a life expectancy of six (6) months or less. Review of the physician progress notes [REDACTED]. 3. Interview During an interview on 02/09/17 at 9:15 a.m., MDS Coordinator #24 said Resident #43 had three (3) falls since the last MDS assessment, inlcuding one (1) fall on 11/09/16, and two (2) falls on 01/05/17. She further verified this should have been noted on the quarterly MDS with ARD of 02/05/17. In addition, she verified the resident had a decline in condition and was restarted on hospice services on 10/24/16. The MDS Coordinator confirmed the MDS with an ARD of 02/05/17 was inaccurate in the areas of falls and hospice/prognosis. b) Resident #51 Review of the medical record on 02/08/17 found the admission minimum data set (MDS), with assessment reference date (ARD) 09/02/16, assessed her weight at 255 pounds. The thirty (30) day MDS, with ARD of 10/03/16, assessed her weight at 237 pounds. This amounted to a seven (7) percent weight loss of eighteen (18) pounds. The thirty (30) day MDS erroneously assessed her as having no weight loss of greater than five (5) percent in the past month. An interview was conducted with MDS registered nurse, Employee #26 on 02/08/17 at 8:52 a.m. She reviewed the resident's MDS weight assessments and the resident's weights recorded in the computer. She agreed the resident sustained [REDACTED]. Employee #26 said she believed this was an expected weight loss resulting from a loss of [MEDICAL CONDITION], so she elected to assess her with no weight loss. She said the 30-day MDS should have assessed her with a weight loss greater than five (5) percent, and it did not. These findings were shared with the director of nursing on 1:10 p.m. on 02/09/17. The facility provided no further information prior to exit. | 2020-09-01 |
| 3276 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 279 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) one (1) resident reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey (QIS). The care plan failed to address how the physician ordered fluid restriction would be implemented and monitored by each discipline, including dietary, nursing and activities. Resident identifier: #40. Facility census: 58. Findings include: a) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs/symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with Registered Nurse (RN) #26, author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's Licensed Practical Nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz's of milk. She was asked how to convert ounces to cubic centimeters. She said she wasn't sure, but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters a day from dietary and 1 cc would equal 1 milliliter. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17. AA #37 confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive four (4) ounces (oz) of coffee or hot tea and 8 oz of milk. As the fluid restriction was 1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 milliliters of fluid at 6:43 p.m. No other fluids were recorded on 02/06/17. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 milliliters of fluids. The DON said that did not indicate this was all the resident drank for the day. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident. | 2020-09-01 |
| 3277 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 280 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise the care plans for Residents #30, #9 and Resident #43's when there was a change in their treatment. Resident #30 and #43 did not have their care plans revised when changes were made to their medication regimen. Resident #9's care plan was not revised when her pressure ulcer interventions changed. For Resident #97 the facility failed to involve him in his care planning process as it related to his preference to have meat for breakfast. This was true for four (4) of seventeen (17) stage 2 sampled residents. Resident Identifiers: #30, #97, #9 and #43. Facility census: 58. Findings include: a) Resident #30 A review of Resident #30's medical record, at 9:22 a.m. on 02/08/17, found a physician's orders [REDACTED]. This order had a discontinue date of 07/08/16. A review of Resident #30's care plan found the following intervention related to her nutritional status problem statement, Administer medications as ordered and monitor for side effects. Med Pass and sliding scale insulin. This intervention had a start date of 03/16/16. An interview with the Director of Nursing (DON) on 02/09/17 at 10:02 a.m., confirmed Resident #30 no longer received sliding scale insulin and the care plan was not revised when this medication was discontinued. b) Resident #97 The medical record was reviewed on 02/07/17 at 11:53 a.m. which revealed a diet order dated 2/01/17 for the resident to receive, double meat/egg portions on trays. On 02/08/17 at 7:54 a.m. Staff #94 stated the resident discussed food preferences with the Registered Dietician on 02/07/17 and because the resident receives [MEDICAL TREATMENT], cannot receive meats served at breakfast. Observed Resident #97 breakfast tray on 02/08/17 at 8:17 a.m., no meat observed on tray. Resident stated understanding of diet recommendations. Resident does not want meat all the time but would like meat sometimes at breakfast but has not received meat with breakfast since admission. On 02/8/17 at 8:49 a.m., an interview with the Registered Dietician stated diet plans came from corporate and cannot be changed. The Registered Dietician stated a conversation will be held with the resident to discuss food preferences and together they can determine what menu options will work. The Dietician stated that perhaps bacon or sausage can be offered occasionally. On 02/08/17 at 10:49 a.m. Staff #94 stated a conversation was held with the resident and meat will be offered at breakfast. c) Resident #9 On 02/07/17 the medical record was reviewed. This resident first came to the facility in 2012. Pertinent [DIAGNOSES REDACTED]. She was always incontinent of bladder. She was totally dependent on staff for toileting. She had impairments of one side of both the upper and the lower extremity. A wheelchair was her only mobility device. Review of a nurse progress note dated 01/20/16, found that a nurse aide brought to the attention of a licensed practical nurse the discovery of a pressure ulcer. Review of the wound assessment and progress review sheets found nursing staff assessed this resident on 01/20/16 with a Stage III pressure ulcer on the coccyx. The tissue type assessed at that time was necrotic slough. Nursing assessed the size at that time as 1.0 centimeter (cm) by 1.5 cm by less than 0.5 cm. The wound had a scant amount of exudate. The facility utilized a Pressure Ulcer Scale for Healing (PUSH) scale that was developed by the national Pressure Ulcer Advisory Panel (NPUAP) as a tool to monitor the improvement or deterioration in pressure ulcer healing using a numerical score. Zero is the best possible score. Review of PUSH scores from 01/20/16 through 02/01/17 found that the pressure ulcer alternately improved and worsened throughout its course. The PUSH scores have ranged from as low as two (2) to as high as nine (9). The most recent PUSH score was seven (7) on 02/01/17. An interview was conducted with wound care registered nurse #80 on 02/07/2017 at 12:44 p.m. She said the pressure ulcer was first identified on 01/20/16 as a Stage III. She said the wound was in-house acquired. When asked about impediments to healing, she said this resident sits a lot. During an interview on 02/07/17 at 12:44 p.m. with licensed practical nurse #22, she said the resident prefers to get up at 3:30 a.m. or 4:00 a.m. daily. She said the resident stays up all day, and goes to bed around 3:30 p.m. or thereafter. An interview was completed with nurse aide (NA) #69 on 02/07/17 at 2:00 p.m. She said the resident gets up really early and sits up in her wheelchair all day. She said sometimes the resident can shift her weight in the wheelchair herself, but some days cannot or does not. The current care plan was reviewed. It directed incontinence care every two (2) hours and as needed, to turn and reposition her at least every two (2) hours. The care plan was silent regarding the resident's preference to stay up in the wheelchair all day long up to twelve (12) hours per day. The care plan was silent regarding the need to shift her position in the wheelchair at set parameters. An interview was completed with the director of nursing (DON) on 02/07/17 at 4:00 p.m. The DON said the resident prefers to stay up in the wheelchair all day long. When asked if she had individualized care planning revisions to note that she is up all day in the wheelchair and required shifts of position when sitting in the wheelchair per set parameters by the facility, she said the aides change her incontinence brief every two (2) hours, so she would be assisted to reposition throughout the day at least every two (2) hours. The facility's policy on the prevention of pressure ulcers was requested to the DON on 02/09/17 at 9:00 a.m., and was soon provided. Review of this policy found general preventive measures for a person in a chair included to change their position at least every hour. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. Review of the current care plan found neither of these interventions listed. During an interview with the DON on 02/09/17 at 1:10 p.m., no further information was provided when informed of the findings of the absence of individualized care plan revisions for this resident who sits up in the chair half of each day. d) Resident #43 Minimum Data Set (MDS) review, with an Assessment Reference Date (ARD) of 02/05/17, revealed this resident received antianxiety, antidepressant, and diuretic. He did not receive antipsychotic, hypnotic, anticoagulant, and antibiotic. Review of the care plan found the identification of the use of Ivanz (antibiotic), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (heart and blood pressure), [MEDICATION NAME] (diabetes) and Two cal HN ( protein supplement). During interview with the MDS nurse #24, on 02/09/17 at 9:15 a.m., review of the current physician orders [REDACTED]. The MDS nurse #24 confirmed the resident no longer was ordered Inanz, [MEDICATION NAME] and Two cal HN. She further acknowledged she needed to revise Resident #43's care plan. | 2020-09-01 |
| 3278 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 282 | E | 0 | 1 | UXFJ11 | Based on resident interview, resident observation, record review and staff interview the facility failed to implement Resident #30's activities of daily living (ADL) care plan on multiple occasions by not providing her showers three times weekly and by not cleaning her glasses every shift as directed by her care plan. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #30. Facility census: 58. Findings include: a) Resident #30 1. Showers During a Stage 1interview with Resident #30, at 3:00 p.m. on 02/06/17, when asked if she received the number of showers in a week she would like she stated, No, I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 8:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: --Problem statement with a start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. --The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. --The interventions associated with this problem statement and goal included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: --For 06/20/16 through 06/30/16, Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower as scheduled on 06/21/16, 06/23/16, and 06/30/16. --For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16), Resident #30 was scheduled to receive 12 showers. She received a shower on 07/05/16, 07/11/16, 07/19/16, and 07/31/16, four (4) of the 12 opportunities. She was out of the facility on 07/07/16 resulting in her not receiving her scheduled shower on this date. Resident #30 had documented refusals of showers on 07/21/16 and 7/23/16. On 07/02/16, 07/09/16, 07/14/16, 07/16/16, and 07/27/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (08/01/16 through 08/30/16), Resident #30's shower schedule was changed to only receiving two showers per week. This change took place on the week of 08/14/16 and has remained the schedule until present. Documentation was not provided by the facility for the week of 08/07/16 through 08/13/16 therefore it is assumed Resident #13 did not recieve a shower during this week. During the month of August, Resident #30 was scheduled to receive nine (9) showers, she only received four (4) on 08/02/16, 08/23/16, 08/27/16, and 08/30/16. She had a documented refusal on 08/20/16. She did not receive a shower four (4) of the scheduled day on 08/06/17, 08/09/16, 08/12/16, and 08/16/16. The record contained no documented reason as to why she did not receive her showers on these dates. --For the month of (MONTH) (YEAR) (09/01/16 through 09/30/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 09/06/16, 09/17/16, and 09/23/16, three (3) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 09/13/16 and 9/30/16. On 09/03/16, 09/10/16, 09/19/16, and 09/26/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (10/01/16 through 10/31/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 10/07/16, 10/14/16, 10/20/16, 10/24/16 and 10/28/16, five (5) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 10/03/16, 10/10/16, and 10/16/16. On 10/31/16, Resident #30 did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (11/01/16 through 11/30/16), Resident #30 was scheduled to receive eight (8) showers. She received a shower on 11/04/16, 11/07/16, and 11/21/16, three (3) of the eight (8) opportunities. Resident #30 had a documented refusal of a shower on 11/14/16. On 11/11/16, 11/25/16, and 11/28/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (12/01/16 through 12/31/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 12/02/16, 12/19/16, and 12/26/16, three (3) of the nine (9) opportunities. Resident #30 had a documented refusal of a shower on 12/09/16. On 12/05/16, 12/12/16, 12/16/16, and 12/26/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (01/01/17 through 01/31/17), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 01/02/17, and 01/16/17, two (2) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 01/06/17 and 01/13/17. On 01/09/17, 01/20/17, 01/23/17, 1/27/17, and 01/30/17 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (02/01/17 through 02/07/17 the day of this review), Resident #30 was scheduled to receive two (2) showers. She received a shower on 02/06/17. However, for 02/02/17, the resident did not receive a shower and the record contained no documented reason. Please note from (MONTH) (YEAR) through present the facility only scheduled Resident #30 for two (2) showers per week. This is not in agreement with the residents care plan and/or the resident interview both of which revealed she should be scheduled for three (3) showers per week. So in addition to the missed showers mentioned above there is one (1) shower per week for 25 weeks that has not even been scheduled or offered to the resident. The Director of Nursing (DON) at 2:00 p.m. on 02/08/17, in an interview stated, The resident was switched to two (2) showers per week per her request. When asked why the care plan still indicated to offer her a shower three (3) times a week she stated, I guess we did not update it. She was then informed Resident #30 had stated she was scheduled to receive three (3) showers per week and she was not getting them. To this she replied, she does not have capacity. A review of Resident #30's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/16 found, her Brief Interview of Mental Status (BIMS) score was a 15 out of 15 indicating she was cognitively intact and fully capable of being interviewed. The DON then reviewed the shower documentation and stated, It looks like our documentation is incomplete, but we are giving her showers. She stated, I think they are forgetting to document refusals on the shower schedule sheet. She was asked to provide any documentation she might have pertaining to the residents request for only two (2) showers per week or that she might have regarding her refusals. She provided no additional information. The DON was then asked to Review Resident #30's care plan she agreed the care plan contained the intervention to shower the resident three times weekly and to clean her glasses every shift. 2. Glasses An observation of Resident #30, on 02/06/17 at 3:00 p.m., found her glasses were unclean and smudged. An additional observation of Resident #30, on 02/09/17 at 8:50 a.m., found her glasses were still dirty and were still smudged in the same place as they were on 02/06/17. At this time Resident #30 was asked if her glasses were working good for her and she stated, Well they could be cleaned and I might see a little better. At this time, Registered Nurse (RN) #52 was asked to come to Resident #30's room to see if her glasses needed to be cleaned. RN #52 took Resident #30's glasses and cleaned them and handed them back to the resident. Resident #30 put her glasses back on and stated, There just like new now. She then thanked RN #52 for cleaning her glasses and also thanked the surveyor for getting someone to clean her glasses for her. A review of Resident #30's medical record, at 08:29 a.m. on 02/09/17, found the following care plan related to Resident #30's ADL care: --Problem Statement with a start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. --The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. --The goals associated with this problem statement and goals included: Vision: Adequate, wears glasses. Clean glasses every shift. | 2020-09-01 |
| 3279 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 309 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, resident interview and staff interview, the facility failed to ensure medication was administered as ordered by the physician, failed to coordinate hospice services and failed on multiple occasions when neurological checks directed by the facility's standing orders for Resident #43. For Resident #97, the facility failed to coordinate [MEDICAL TREATMENT] treatments. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview with register nurse (RN) # 52 on 02/09/17 at 8:25 a.m., found the facility staff was unable to provide information for when the hospice personnel were scheduled and who was responsible for the coordination of hospice care with the facility and hospice staff. 3. Neurological checks Review of Resident #43's incident reports found on 08/29/16, 10/19/16, 11/09/16 and 01/05/17 he was ordered neurological (neuro-checks) due to unwitnessed and/or complaint or indication of a head injury as directed in the facility's standing orders for incidents. Incident reports directed the neuro-checks to be done: --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consecutive times, then --Every four (4) hours - two (2) consecutive times, then --Every shift - three (3) consecutive times. The neurological assessment form used by the facility's staff instructed to obtain neuro-checks: --Every fifteen (15) minutes - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Once a shift for 24 hours. The facility's standing orders directed to complete neuro-checks: --Every fifteen (15) - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Every hour - two (2) consecutive times, then --Once a shift for 24 hours. Interview with the DON on 02/09/17 at 3:00 p.m., found she was unaware of the different directions used for the neuro-checks (incident report, neuro- check forms used by the licensed nurses and facility's standing orders). She confirmed the facility's standing order for neuro-checks should be used. She further confirmed the neuro-checks for Resident #43 for 08/29/16, 10/19/16, 11/09/16 and 01/05/17 had not been completed as directed by the facility's standing orders. b) Resident #97 On 02/07/17 at 11:58 a.m., review of the medical record reflected a care plan dated 01/26/17 that read, communicate with [MEDICAL TREATMENT] center. On 02/07/17 at 1:2:40 p.m., a record review revealed incomplete [MEDICAL TREATMENT] communication forms. On 02/07/17 at 12:50 p.m., an interview with licensed practical nurse (LPN) #23 assigned to care for Resident #97 stated she does not know where the [MEDICAL TREATMENT] communication form are kept in the medical record. On 02/07/17 at 2:58 p.m., registered nurse (RN) #8 stated that she was unsure of where the [MEDICAL TREATMENT] communication forms are filed in the medical record. On 02/08/17 at 8:00 a.m., a review of the, Outpatient [MEDICAL TREATMENT] Services Agreement revealed, The Facility will provide for the interchange of information useful or necessary for the care of the resident. On 02/07/17 at 2:49 p.m., the director of nursing (DON) stated that the [MEDICAL TREATMENT] Center never returns the [MEDICAL TREATMENT] communication form when Resident #97 returns to the facility and it is a problem. . c) Resident #30 A review of Resident #30's medical record at 9:51 a.m. on 02/09/2017, found the resident had fallen on 09/12/16 at 4:00 p.m. A review of the incident report found the following order for a fall with suspected head trauma to initiate neurological checks (neuro checks): --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consectuive times, then --Every two (2) hours - two (2) consectuive times, then --Every four (4) hours - two (2) consectuive times, then --Every shift- - three (3) consectuive times, then Further review of the record found a nursing note dated 09/12/16 which indicated Resident #30 was sent to a local hospital emergency department at 6:35 p.m. on 09/12/16. Prior to Resident #30 leaving the facility she should have had a neuro check at 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 6:00 p.m. upon review of the record no neuro checks could be located. At 12:24 p.m. on 02/09/17, registered nurse (RN) #80 indicated Resident #30 did not have any neuro checks because she was sent to the emergency room . She was asked to review the nurses note which indicated Resident #30 did not leave the facility until 6:35 p.m. on 09/12/16. She was then asked if the staff should have initiated the neuro checks during the two (2) and a half hours the resident remained at the facility. She agreed they should have initiated the neuro checks and indicated she would go and look for them. In an interview with the director of nursing (DON) on 02/09/17 at 1:06 p.m., she confirmed they could not find were they done the neuro checks for Resident #30. d) Resident #42 Medical record review on 02/09/17 revealed his resident sustained [REDACTED]. The facility's standing physician's orders [REDACTED]. The neuro checks must begin immediately, then every fifteen (15) minutes for four (4) times; every thirty (30) minutes for two (2) times; every hour for two (2) times, then once per shift for twenty-four (24) hours. This amounted to a minimum of eleven (11) neuro check evaluations. Review of the POS [REDACTED]. At the top of these forms it stated, This assessment should be completed at the following intervals for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Review of this resident's neuro check forms found numerous absences of vital sign and neurological assessments as follows: --10/31/16 - Blood pressure, pulse, respiration, and orientation was assessed ten (10) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. There was no evidence of any assessment of pupil size and reaction. --12/09/16 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. Pupil size and reaction was assessed eight (8) out of eleven (11) opportunities. --01/25/17 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of upper extremities was assessed nine (9) out of eleven (11) opportunities. Strength of lower extremities was assessed five (5) out of eleven (11) opportunities. Pupil size and reaction was assessed five (5) out of eleven (11) opportunities. During an interview with the director of nursing on 02/09/17 at 1:10 p.m., she agreed nursing staff did not obtain neurological assessments consistently as the physician's standing orders directed. e) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs and symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with registered nurse (RN), author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's licensed practical nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager, (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz of milk. She was asked how to convert ounces to cubic centimeters (cc) She said she wasn't sure but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters (ml) a day from dietary and 1 cc would equal 1 ml. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17, she confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive 4 oz of coffee or hot tea and 8 oz of milk. As the fluid restriction was1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 ml of fluid at 6:43 p.m. No other fluids were recorded. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 ml of fluids. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident. | 2020-09-01 |
| 3280 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 312 | E | 0 | 1 | UXFJ11 | Based on resident interview, resident observation, record review and staff interview the facility failed to provide Resident #30 who is not able to carry out her own Activities of Daily Living (ADL) care with the necessary ADL care for her to maintain good grooming, and personal hygiene. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during stage 2 of the quality indicator survey (QIS). Resident Identifiers: #30. Facility Census: 58. Findings include: a) Resident #30 1. Showers During a Stage one (1) interview with Resident #30 at 3:00 p.m. on 02/06/17 when asked if she received the number of showers in a week she would like she stated, No I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 08:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: Problem Statement with a problem start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. The goals associated with this problem statement and goals included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: 06/20/16 through 06/30/16: Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower scheduled on 06/21/16, 06/23/16, and 06/30/16. For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16) Resident #30 was scheduled to receive 12 showers. She received a shower on 07/05/16, 07/11/16, 07/19/16, and 07/31/16 four (4) of the 12 opportunities. She was out of the facility on 07/07/16 resulting in her not receiving her scheduled shower on this date. Resident #30 had documented refusals of showers on 07/21/16 and 7/23/16. On 07/02/16, 07/09/16, 07/14/16, 07/16/16, and 07/27/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (08/01/16 through 08/30/16) Resident #30's shower schedule was changed to two (2) showers per week. This change took place on the week of 08/14/16 and has remained the schedule until present. Documentation was not provided by the facility for the week of 08/07/16 through 08/13/16. During the month of (MONTH) Resident #30 was scheduled to receive nine (9) showers she only received four (4) on 08/02/16, 08/23/16, 08/27/16, and 08/30/16. She had a documented refusal on 08/20/16. She did not receive a shower four (4) of the scheduled days on 08/06/17, 08/09/16, 08/12/16, and 08/16/16. The record contained no documented reason as to why she did not receive her showers on these dates. For the month of (MONTH) (YEAR) (09/01/16 through 09/30/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 09/06/16, 09/17/16, and 09/23/16 three (3) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 09/13/16 and 9/30/16. On 09/03/16, 09/10/16, 09/19/16, and 09/26/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (10/01/16 through 10/31/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 10/07/16, 10/14/16, 10/20/16, 10/24/16 and 10/28/16 five (5) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 10/03/16, 10/10/16, and 10/16/16. On 10/31/16 Resident #30 did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (11/01/16 through 11/30/16) Resident #30 was scheduled to receive eight (8) showers. She received a shower on 11/04/16, 11/07/16, and 11/21/16 three (3) of the eight (8) opportunities. Resident #30 had a documented refusal of a shower on 11/14/16. On 11/11/16, 11/25/16, and 11/28/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (12/01/16 through 12/31/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 12/02/16, 12/19/16, and 12/26/16. three (3) of the nine (9) opportunities. Resident #30 had documented refusal of a shower on 12/09/16. On 12/05/16, 12/12/16, 12/16/16, and 12/26/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (01/01/17 through 01/31/17) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 01/02/17, and 01/16/17 two (2) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 01/06/17 and 01/13/17. On 01/09/17, 01/20/17, 01/23/17, 1/27/17, and 01/30/17 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (02/01/17 through 02/07/17 the day of this review) Resident #30 was scheduled to receive two (2) showers. She received a shower on 02/06/17. However, for 02/02/17 the resident did not receive a shower and the record contained no documented reason. Please note from (MONTH) (YEAR) through present the facility only scheduled Resident #30 for two (2) showers per week. This is not in agreement with the residents care plan and/or the resident interview both of which revealed she should be scheduled for three (3) showers per week. So in addition to the missed showers mentioned above there is one (1) shower per week for 25 weeks that has not even been scheduled or offered to the resident. The Director of Nursing (DON) at 2:00 p.m. on 02/08/17, in an interview stated, The resident was switched to two (2) showers per week per her request. When asked why the care plan still indicated to offer her a shower three (3) times a week she stated, I guess we did not update it. She was then informed Resident #30 had stated she was scheduled to receive three (3) showers per week and she was not getting them. To this she replied, she does not have capacity. A review of Resident #30,s most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/16 found, her Brief Interview of Mental Status (BIMS) score was a 15 out of 15 indicating she was cognitively intact and fully able to be interviewed. The DON then reviewed the shower documentation and stated, It looks like our documentation is incomplete, but we are giving her showers. She stated, I think they are forgetting to document refusals on the shower schedule sheet. She was asked to provide any documentation she might have pertaining to the residents request for only two (2) showers per week or that she might have regarding her refusals. She provided no additional information. 2. Glasses An observation of Resident #30 on 02/06/17 at 3:00 p.m. found her glasses were unclean and smudged. An additional observation for Resident #30 on 02/09/17 at 8:50 a.m. found her glasses were still dirty and were still smudged in the same place as they were on 02/06/17. At this time Resident #30 asked if her glasses were working good for her and she stated, Well they could be cleaned and I might see a little better. At this time Registered Nurse (RN) #52 was asked to come to Resident #30's room to see if her glasses needed to be cleaned. RN #52 took Resident #30's glasses and cleaned them and handed them back to the resident. Resident #30 put her glasses back on and stated, They're just like new now. She then thanked RN #52 for cleaning her glasses and also thanked the surveyor for getting someone to clean her glasses for her. A review of Resident #30's medical record at 08:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: Problem Statement with a problem start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. The goals associated with this problem statement and goals included: Vision: Adequate, wears glasses. Clean glasses every shift. | 2020-09-01 |
| 3281 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 353 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. Resident #43 was not administered a breathing ([MEDICATION NAME]) medication as ordered by the physician, failed to ensure the care of a hospice resident was correlate his hospice provider and failed on multiple occasions when neurological checks were indicated to complete as directed by the facility's standing orders. For Resident #97 the facility failed to ensure the care of a [MEDICAL TREATMENT] resident was correlated with the [MEDICAL TREATMENT] center. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview with register nurse (RN) # 52 on 02/09/17 at 8:25 a.m., found the facility staff was unable to provide information for when the hospice personnel were scheduled and who was responsible for the coordination of hospice care with the facility and hospice staff. 3. Neurological checks Review of Resident #43's incident reports found on 08/29/16, 10/19/16, 11/09/16 and 01/05/17 he was ordered neurological (neuro-checks) due to unwitnessed and/or complaint or indication of a head injury as directed in the facility's standing orders for incidents. Incident reports directed the neuro-checks to be done: --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consecutive times, then --Every four (4) hours - two (2) consecutive times, then --Every shift - three (3) consecutive times. The neurological assessment form used by the facility's staff instructed to obtain neuro-checks: --Every fifteen (15) minutes - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Once a shift for 24 hours. The facility's standing orders directed to complete neuro-checks: --Every fifteen (15) - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Every hour - two (2) consecutive times, then --Once a shift for 24 hours. Interview with the DON on 02/09/17 at 3:00 p.m., found she was unaware of the different directions used for the neuro-checks (incident report, neuro- check forms used by the licensed nurses and facility's standing orders). She confirmed the facility's standing order for neuro-checks should be used. She further confirmed the neuro-checks for Resident #43 for 08/29/16, 10/19/16, 11/09/16 and 01/05/17 had not been completed as directed by the facility's standing orders. b) Resident #97 On 02/07/17 at 11:58 a.m., review of the medical record reflected a care plan dated 01/26/17 that read, communicate with [MEDICAL TREATMENT] center. On 02/07/17 at 1:2:40 p.m., a record review revealed incomplete [MEDICAL TREATMENT] communication forms. On 02/07/17 at 12:50 p.m., an interview with licensed practical nurse (LPN) #23 assigned to care for Resident #97 stated she does not know where the [MEDICAL TREATMENT] communication form are kept in the medical record. On 02/07/17 at 2:58 p.m., registered nurse (RN) #8 stated that she was unsure of where the [MEDICAL TREATMENT] communication forms are filed in the medical record. On 02/08/17 at 8:00 a.m., a review of the, Outpatient [MEDICAL TREATMENT] Services Agreement revealed, The Facility will provide for the interchange of information useful or necessary for the care of the resident. On 02/07/17 at 2:49 p.m., the director of nursing (DON) stated that the [MEDICAL TREATMENT] Center never returns the [MEDICAL TREATMENT] communication form when Resident #97 returns to the facility and it is a problem. c) Resident #30 A review of Resident #30's medical record at 9:51 a.m. on 02/09/2017, found the resident had fallen on 09/12/16 at 4:00 p.m. A review of the incident report found the following order for a fall with suspected head trauma to initiate neurological checks (neuro checks): --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consectuive times, then --Every two (2) hours - two (2) consectuive times, then --Every four (4) hours - two (2) consectuive times, then --Every shift- - three (3) consectuive times, then Further review of the record found a nursing note dated 09/12/16 which indicated Resident #30 was sent to a local hospital emergency department at 6:35 p.m. on 09/12/16. Prior to Resident #30 leaving the facility she should have had a neuro check at 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 6:00 p.m. upon review of the record no neuro checks could be located. At 12:24 p.m. on 02/09/17, registered nurse (RN) #80 indicated Resident #30 did not have any neuro checks because she was sent to the emergency room . She was asked to review the nurses note which indicated Resident #30 did not leave the facility until 6:35 p.m. on 09/12/16. She was then asked if the staff should have initiated the neuro checks during the two (2) and a half hours the resident remained at the facility. She agreed they should have initiated the neuro checks and indicated she would go and look for them. In an interview with the director of nursing (DON) on 02/09/17 at 1:06 p.m., she confirmed they could not find were they done the neuro checks for Resident #30. d) Resident #42 Medical record review on 02/09/17 revealed his resident sustained [REDACTED]. The facility's standing physician's orders [REDACTED]. The neuro checks must begin immediately, then every fifteen (15) minutes for four (4) times; every thirty (30) minutes for two (2) times; every hour for two (2) times, then once per shift for twenty-four (24) hours. This amounted to a minimum of eleven (11) neuro check evaluations. Review of the POS [REDACTED]. At the top of these forms it stated, This assessment should be completed at the following intervals for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Review of this resident's neuro check forms found numerous absences of vital sign and neurological assessments as follows: --10/31/16 - Blood pressure, pulse, respiration, and orientation was assessed ten (10) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. There was no evidence of any assessment of pupil size and reaction. --12/09/16 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. Pupil size and reaction was assessed eight (8) out of eleven (11) opportunities. --01/25/17 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of upper extremities was assessed nine (9) out of eleven (11) opportunities. Strength of lower extremities was assessed five (5) out of eleven (11) opportunities. Pupil size and reaction was assessed five (5) out of eleven (11) opportunities. During an interview with the director of nursing on 02/09/17 at 1:10 p.m., she agreed nursing staff did not obtain neurological assessments consistently as the physician's standing orders directed. e) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs and symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with registered nurse (RN), author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's licensed practical nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager, (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz of milk. She was asked how to convert ounces to cubic centimeters (cc) She said she wasn't sure but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters (ml) a day from dietary and 1 cc would equal 1 ml. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17, she confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive 4 oz of coffee or hot tea and 8 oz of milk. As the fluid restriction was1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 ml of fluid at 6:43 p.m. No other fluids were recorded. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 ml of fluids. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident. | 2020-09-01 |
| 3282 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 356 | B | 0 | 1 | UXFJ11 | Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date; the current resident census; the total number and actual hours worked by registered nurses, licensed nurses, and nurse aides per shift. This had the potential to affect more than an isolated number of residents and/or visitors residing or visiting the facility. Facility census: 58. Findings include: a) Observation of the staff posting on the 2nd floor, during the initial tour of the facility, at 10:34 a.m. on 02/06/17, found the facility staff posting was dated 02/02/17. An interview with the director of nursing, at 10:35 a.m. on 02/06/17, confirmed the facility had not displayed the staff posting information for 02/03/17 through 02/06/17. . | 2020-09-01 |
| 3283 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 371 | F | 0 | 1 | UXFJ11 | Based on observation and staff interview, the facility failed to prepare, store and serve food in a safe and sanitary manner. The kitchen walk-in refrigerator had solid matter where floor and wall meet, undated dry goods, un-intact packaged frozen food observed in walk-in freezer and perishable food stored at room temperature. Resident refrigerators on first and second floor contained unlabeled and/or undated food, and soiled food carts were observed. These findings had the potential to affect all residents. Census: 58. a) The Kitchen Observations made on 02/06/17 and 02/08/17 found the following: --02/06/17 at 10:46 a.m. observed non securely packaged pancakes and chicken patties exposed to air inside walk-in freezer. --02/06/17 at 10:53 a.m. observed solid matter in areas of walk-in refrigerator where floor and wall meet. --02/06/17 at 12:44 p.m. observed single serve milk cartons set out at room temp for the duration of meal tray assembly. --02/06/17 at 12:49 Staff #94 states that once a week the refrigerator floor should be cleaned out and that it is a good idea to put the milk on ice if milk will be setting out for a while. --02/08/17 at 10:22 a.m. observed the following opened, undated food items stored on a shelf, bulk Italian seasoning, molasses, cream of wheat, 2 (two) cans of food thickener and 2 (two) jars of chicken base seasoning. The label on the jars of chicken base seasoning reads, refrigeration after opening is required. --02/08/17 at 10:30 a.m. interview with Staff #94 states that items need to be dated when opened and stored in the proper place. b) Observation of the resident's food pantry refrigerator During the tour of the facility at 10:30 a.m. on 2/6/17, observation of the resident's personal refrigerator, located in the medication administration room, on the 1st floor of the facility found 2 packs of sliced, soft, American, cheese. The cheese was not individually wrapped. One package was dated 1/29/17 with discard date of 2/5/16. The second package of cheese was dated 01/20/17 with a discard date of 01/27/17. The director of nursing (DON) was present during the tour. She identified the first date as the date the cheese was placed in the refrigerator and the second date as the date of discard. She said she would throw away the cheese. In addition, the cheese was wrapped loosely with cellophane wrapping which did not create a seal to ensure the cheese did not dry out. At 1:09 p.m. on 02/08/17, the dietary manager (DM) #94 said the cheese was good for 30 days. When asked for the facility policy, the DM presented a copy of a computer print out from a web cite-www.recipetips.com. The information on the print out noted: --Fresh cheese could be kept in the refrigerator for 1 to 2 days, --Soft cheese could be kept in the refrigerator for 3 to 4 days, and --Hard or semi-hard cheese could be kept for 2 to 3 weeks. --The web cite is not an approved food code from the United States (US) Food and Drug Administration's food code. A second policy entitled, Food and Supple Storage Procedures-continued, only noted to discard leftovers not utilized within 48 hours. c) Observation of the evening meal in the main dining room At 6:35 p.m. on 02/08/17, observation of the evening meal, with the DM, in the main dining room, found the open food cart, being used to serve clean trays, was dirty and covered with debris. The wheels and the legs of the cart were covered with food debris, lint, dust, and dirt. In addition, the racks on the cart, used to slide the trays in and out of the open cart were covered with dried debris. d) Nutrition Refrigerator on 2nd Floor An observation of the nutrition pantry refrigerator on 2nd floor was conducted during the initial tour of the facility on 02/06/17 at 10:30 a.m. The following sanitation issues were identified: one (1) open bottle of mayonnaise, one (1) 240 milliliter 2% milk, one half (1/2) gallon of buttermilk, block of sliced cheese, and a 16 ounce bottle of diet Pepsi all items were found opened and no date or resident name. Employee #79, licensed practical nurse (LPN), was present during the observations of the nutrition pantry refrigerator and confirmed the listed items were not appropriately labeled, and/or were not discarded timely. | 2020-09-01 |
| 3284 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 428 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, medical record reviews, and review of the consultant pharmacist's recommendations, the facility failed to ensure the pharmacist's recommendations which were approved by the attending physician were acted upon. For Resident #43, the consultant pharmacist recommended Theophylline be given twice daily with meals to reduce gastrointestinal (GI) distress and the attending physician approved this recommendation, but nursing failed to implement the recommendation. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Recommendation. Resident identifier: #43. Facility census: 58. Findings include: a) Resident #43 A review of Resident #43's medical record, at 10:19 a.m. on 02/08/17, found the following a consultant pharmacist recommendation the attending physician agreed to follow on 08/18/16, Theophylline Extended Release (ER) one tablet by mouth twice daily with meals to reduce gastrointestinal (GI) distress Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing, at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. She confirmed the consultant pharmacist recommendation was agreed to by the attending physician on 08/18/16 and was not administered as directed. | 2020-09-01 |
| 3285 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 431 | E | 0 | 1 | UXFJ11 | Based on observation, staff interview, and policy review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Two (2) multi-dose vials of insulin which belonged to Residents #77 and #27 were open and had no date, and/or legible date to indicate when the vials were initially opened. Use of medication from multi-dose vials open for a time period greater than recommended by the manufacturer had the potential to negatively impact the safety and/or potency of the medication. Observation of the first floor medication room refrigerator found it was not at the appropriate temperature. This had the potential to affect more than a limited number of residents. Resident identifiers: #77 and #27. Facility census: 58. Findings include: a) Resident #77 Observation on 02/07/17 at 9:07 a.m., found an opened, partially used, ten (10) milliliter (ml) vial of Humulin R insulin. The vial contained no date indicating when it was initially opened. Licensed practical nurse (LPN) #22 said nurses discard vials of Humulin-R insulin thirty (30) days after the date they are opened. She agreed the vial was not marked with the date it was initially used or opened . She discarded the opened vial, and obtained a new, unopened vial of Humulin-R insulin for this resident's use. During an interview with the director of nursing on 02/08/17 at 4:15 p.m., she said nursing staff are supposed to date all multi-dose vials of insulin when they are first opened. b) Resident #27 Observation on 02/08/17 at 4:15 p.m., found an opened, nearly empty, ten (10) ml vial of Levemir insulin. The vial contained an illegible inscription of the date when it was initially opened. The director of nursing (DON) was present at this time, and said she would dispose of this vial since it cannot be accurately determined when it was initially opened. She said nursing staff is supposed to date all multi-dose vials of insulin when they are first opened. She said the opened date on this vial was smudged and illegible. She agreed that Levemir insulin vials should be discarded forty-two (42) days after it is initially opened. The DON provided a copy of the facility's insulin administration policy. In part, the policy directed to check the expiration date of the vial if drawing from an opened multi-dose vial of insulin. If opening a new vial, the policy contained a directive to record the expiration date on the vial. The policy directed to follow manufacturer's recommendations for expiration after opening. | 2020-09-01 |
| 3286 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 441 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manual for glucometer care, the facility failed to ensure an effective infection control program designed to prevent the development and/or transmission of disease and infection to the extent possible. Potential for cross-contamination was observed when nursing staff placed reusable patient care supplies directly onto residents' overbed trays without any type of barrier; nursing staff demonstrated improper cleaning and/or disinfection of a resident-shared glucometer after use; nursing staff touched inanimate objects in a resident's semi-private room without first removing disposable latex gloves previously used while cleaning an incontinent resident; nursing staff soaked washcloths in a resident sink prior to use for incontinence care. These practices had the potential to affect more than a limited number of residents on the first floor long hall, but most directly involved Residents #50, #95, #29. Resident identifiers: #50, #95, #29. Facility census: 58. Findings include: a) Resident #50 During observation on 02/07/17 at 7:22 a.m., licensed practical nurse (LPN) #22 placed a glucometer (small machine used to obtain blood glucose tests) directly onto this resident's overbed tray without the use of any type of barrier. After the test was completed, LPN #22 placed the glucometer directly onto the top of the medication cart. This act contaminated the top of the medication cart, which is where a nurse would pour medications for other residents. She then obtained a wipe from a canister and proceeded to wipe off the glucometer before returning the glucometer to the drawer of the medication cart. Observation of the canister found its only active ingredient was a seventy percent (70%) alcohol solution. She did not clean and/or disinfect the top of the medication cart where the glucometer had been placed. During interview with the director of nursing (DON) on 02/08/2017 9:06 a.m., she said there is no need to place the glucometer on any residents' bedside tray. Rather, the nurses are supposed to carry the machine into the resident's room and hold the glucometer in their hands. She said if a nurse laid the glucometer down in the room, a barrier would be needed such as a paper towel. She agreed that when the nurse laid the glucometer on top of the medication cart after it had previously placed directly on the resident's overbed tray, the nurse should have wiped off the top of the medication cart with a disinfectant wipe from the red lidded Med Line Micro Kill canister. The DON said each cart has either packets of sani-wipes with bleach especially made to clean glucometers between patient uses, and/or canisters with red lids of Med Line Micro Kill that are EPA (environmental protection act) registered to disinfect surfaces and glucometers. She said LPN #22 used a sanitizing wipe from the blue lidded canister whose only active ingredient was 70% alcohol. She said those wipes are used only to clean hands. The DON said this canister with 70% alcohol had no EPA registration. The DON provided the facility's glucometer manufacturer's booklet which listed several product brands on pages 43 and 44 which may be used to disinfect the glucometer between patient uses. Both the Med Line Micro Kill and the individual packets of bleach wipes the facility used were included in the list of approved product brands. The blue lidded canister of 70% alcohol wipes was not included in the list of approved product brands to disinfect the glucometer. b) Resident #95 During observation on 02/07/17 at 9:52 a.m., LPN #22 carried a medication box into this resident's room. The box contained an [MEDICATION NAME] hand-held inhaler. LPN #22 placed the box on the resident's beside table with no barrier beneath it. After the resident used the inhaler, LPN #22 placed the inhaler back into the medication box. She then placed the medication box on the countertop of the resident's sink while she washed her hands. Next, she placed the medication box on top of her medication cart while she unlocked the cart. She then returned the medication box which contained the [MEDICATION NAME] inhaler to a drawer of the medication cart. She did not sanitize the medication box after it had been in contact with the resident's overbed tray and sink. She did not sanitize the top of her medication cart after the exposed medication box was placed on it. During an interview with the director of nursing (DON) on 02/08/17 at 9:06 a.m., she said if a nurse placed an inhaler's medication box on an overbed tray, the nurse should place the box on a barrier such as a paper towel. Otherwise, this could potentially cause cross contamination. She agreed that the nurse should also have sanitized/disinfected the top of her medication cart after the exposed medication box had been placed on it. c) Resident #29 On 02/08/17 at 7:25 p.m., nurse aide (NA) #38 performed urinary incontinence care for Resident #29. She placed clean wash cloths directly into the resident's sink beneath the faucets and atop the drain, and ran warm water over the wash cloths. She squirted some red-colored shower wash onto the washcloth, squeezed out the excess water, then placed the wash clothes on the sink's counter top. The NA stripped the resident's bed. She then assisted the resident into the bathroom, and donned a pair of disposable green gloves. The resident held to the grab bar in the bathroom as she removed his wet diaper. When she removed the diaper, the urine odor was quite acrid and pungent with the strong smell of ammonia. She wiped the front of him, then washed his buttocks. She applied a clean diaper, and helped him into a pair of clean sweat pants. While still wearing the same gloves, she touched the bathroom door, went to his closet, touched numerous items of clothing hanging in the closet before selecting a green shirt. She returned to the bathroom with the shirt, removed his old shirt which she said was wet, and helped him into the clean shirt. Still wearing the same gloves, she took hold of the wheelchair and helped him out of the bathroom and wheeled him by his bed. She placed the bed linens, soiled pants and shirt into a clear plastic bag. At this time, she removed her contaminated gloves. She took the bagged clothing and linens out of the room. A minute or so later, NA #38 returned with a canister of Micro Kill Med Line disinfectant wipes, and placed the canister on his overbed table with no barrier beneath it. She wore disposable gloves, and pulled out a couple of sanitizing wipes and began wiping down his mattress. Upon inquiry, she said staff wipe down the mattresses with these wipes every time they change the sheets. She said she obtained this canister from the common use shower room. On 02/09/17 at 9:45 a.m., an interview was completed with the director of nursing (DON). We discussed the details of the incontinence care of the preceding evening. The DON said the aide should not have placed the washcloths in the resident's sink, or placed the wet washcloths on the sink, as these practices are unsanitary. She said the aide should have filled the resident's wash basin with clean water, and should have taken the basin into the bathroom with her. She agreed that organisms from the sink could have led to cross-contamination of the wash cloths. The DON agreed that the NA should have removed her dirty, contaminated gloves before leaving the bathroom and before touching any of the inanimate objects in the room, as this practice could pose the risk for cross-contamination of organisms into the environment. The DON agreed that the NA should not have brought the shower room canister of Micro Kill wipes into the resident's room, nor should she have placed the canister on the resident's table, as these practices could also contribute to cross-contamination of organisms into the resident's environment. | 2020-09-01 |
| 3287 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 514 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the medical record was complete and accurate for Resident #1 and Resident #43 . The medical record did not contain any documentation concerning the change in legal representative for Resident #1 and the delay completing the required process for making such a change. Resident #43 had a bleeding alert on his physician's orders [REDACTED]. However, the order for [MEDICATION NAME] was discontinued over one (1) year ago. Resident identifiers: #1 and #43. Facility census: 58. Findings include : a) Resident #1 A review of Resident #1's medical record at 1:00 p.m. on 02/07/17 found the resident was admitted to the facility in 2005. Upon her admission to the facility the sheriff of the previous county she resided in was her guardian and conservator. This appointment was made in 1988. This guardian remained in effect until 07/15/16 at which time the[NAME]County Department of Health and Human Resources (DHHR) was appointed to serve at the residents Health Care Surrogate (HCS). This HCS remained in effect until 12/15/16 when the physician appointed Resident #1's cousin to serve as her HCS. Further review of the appointment of the cousin to the position of HCS found the resident was notified of this on 10/19/16 at 3:30 p.m. and was happy the her cousin would be making her decisions, and gestured that she loves her cousin. The form however was not signed by the attending physician until 12/15/16 which is the date the form went into effect. A HCS cannot go into effect until the date the physician signs the form. At 2:15 p.m. on 02/07/17, the facility's Licensed Social Worker (LSW) was interviewed. When asked how the resident's cousin came to be her HCS she stated, (Name of Resident) was under an old committee and the Sheriff of (Name of neighboring county) was making her medical and financial decisions. She indicated, she had started looking into this and did not realize the resident had any family. She stated, She had a committee for so long I did not think there was any family who was interested in making her medical decisions. She stated, In (MONTH) I had not seen (name of residents cousin) come to visit and did not become aware of her visits until (MONTH) (YEAR). She continued by saying, When I realized this cousin was coming to visit I spoke with her about becoming the resident's HCS and she agreed. She indicated, That was when I told (Name of Resident #1) that her cousin would be making her decisions for her. When asked why it took the physician two (2) months to sign the HCS she stated, I think the cousin and I kept missing each other when she would be into visit and it took me awhile to get her to sign the form. She indicated, It should be documented in the record what day she actually signed it. She was then asked to provide any notes from the record that explaining why the HCS was changed and/or why it took two (2) months from the time of resident notification to the physician signing the HCS. She indicated she would print them off the system and provide them. During an additional interview with the Social Worker at 2:40 p.m. on 02/07/2017 she confirmed, she had not entered any notes into the medical record. She stated, I must have forgot to write a note about any of this. b) Resident #43 Review of Resident #43's medical records on 02/08/17 at 1:15 p.m., found on the physician orders [REDACTED]. Further review of Resident #43's physician orders [REDACTED]. Interview with the DON on 02/08/17 at 1:45 p.m. confirmed the alert should have been removed after the [MEDICATION NAME] had been discontinued on 10/28/15. | 2020-09-01 |
| 3288 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 520 | F | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of water temperatures, staff interviews, and resident interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware, or should have been aware. Deficient practices related to quality of life and quality of care were identified during the Quality Indicator Survey (QIS). The issues identified were results of systemic breakdowns in the manner in which the facility staff administered care and services to their residents. The issues had been ongoing for multiple months giving the QA & A committee ample time to identify and correct the deficient practices prior to its QIS survey which began on 02/06/17 and ended on 02/09/17. Quality of Life: The facility failed to maintain an environment which was clean, sanitary, and in good repair. Walls were marred and scratched, door frames and doors were rusted, floor tile was cracked, resident equipment was dirty and/or rusted, shower room floors were dirty, blinds were bent and broken, and facility floors in resident rooms and common areas were dirty. Quality of Care: The facility was notified on 02/08/17 at 6:22 p.m. of an immediate jeopardy (IJ) situation due to elevated water temperatures. It was noted the facility had been monitoring the water temperature and on 02/07/17 had the hot water shut off to room [ROOM NUMBER] and 105 for a period of time. However, on 02/08/17 at 2:21 p.m. the hot water temperature in room [ROOM NUMBER] was 144 degrees and was not turned off, not had the hot water been turned off to the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions had been taken by the facility to ensure resident safety until the problem is resolved. These deficient practices had to potential to affect all residents residing in the facility. Facility Census:58 Findings include: a) The facility failed to ensure the resident environment over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with the maintenance department using the facility's laser thermometer found a water temperature of 130 degrees Fahrenheit (F) at a resident's hand sink. Throughout the survey, measurements of water temperatures found significant fluctuations of water temperatures at different times of the day, and in different rooms at the same time of the day. Additionally, the water temperature would peak, and then drop drastically after the water ran for several minutes. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. Resident identifiers: #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95 and #81. Additionally, review of the facility's water temperature logs found water temperatures were often in excess of 120 degrees F for months without evidence of adjustments or evidence of the effectiveness of the adjustments. This was determined to constitute an immediate jeopardy (IJ) to the health and well-being to more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. 1. Measurement of Water Temperatures Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with a member of the maintenance department using the facility's laser thermometer found the water temperatures in the resident hands sinks in three (3) resident rooms were: -- room [ROOM NUMBER] the water temperature was 130 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 103 degrees F -- room [ROOM NUMBER] the water temperature was 109 degrees F After consulting with the Office of Health Facility Licensure and Certification's (OHFLAC) Life Safety Program Manager on 02/06/17 at 4:00 p.m. concerning the use of a laser thermometer, the facility's maintenance department was asked to use a thermometer that could be immersed in the water in order to obtain a more accurate water temperature. Between 4:15 p.m. and 4:40 p.m. on 02/06/17, water temperature measurements taken with the maintenance department using a submersible thermometer found the following water temperatures in the residents' hand sinks: -- room [ROOM NUMBER] the water temperature was 127.9 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 115.9 degrees F -- room [ROOM NUMBER] the water temperature was 112.9 degrees On 02/07/17, the facility provided a list of water temperatures randomly obtained by maintenance of hand sinks on first floor. The water temperatures ranged from 83.1 to 100.6 degrees F. On 02/08/17 at approximately 2:25 p.m., when washing her hands in the public restroom (room [ROOM NUMBER]), Surveyor noted steam rising from the water. The surveyor could not comfortably hold her hands under the water because it was too hot. Upon request at that time, maintenance obtained water temperatures at residents' hand sinks. On 02/08/17 the water temperatures taken between 2:30 p.m. and 3:00 p.m., found the following: -- room [ROOM NUMBER] the water temperature was 144 degrees F. (According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F.) -- room [ROOM NUMBER] the water temperature was 120.6 degrees F -- Shower room (Bathing 136) the water temperature was 111 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 105.1 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 107.3 degrees F Throughout the survey, significant fluctuations of water temperatures were noted at different times of the day and in different rooms at the same time of the day. The water temperature also decreased if allowed to run for several minutes. The temperature of the water would peak for a few minutes, and then drop drastically. At 4:21 p.m. on 02/08/17, the maintenance director obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 119.2 degrees F. At 5:32 p.m. on 02/08/17, maintenance obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 125.9 degrees F. On 02/07/17, the facility consulted a contractor who found the mixing valve needed replaced, but would not arrive until the morning of 02/09/17. The facility monitored the water temperatures and on 02/07/17, had the hot water shut off to rooms [ROOM NUMBERS] for a period. However, on 02/08/17 at 2:21 p.m. the hot water remained on in room [ROOM NUMBER] and was found to be 144 degrees F. Additionally, the hot water remained on in the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions were taken by the facility to ensure resident safety until the problem was resolved. 2. CMS Guidance to Surveyors According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur at: --120 degrees F with an exposure time of five (5) minutes, --124 degrees F with an exposure time of three (3) minutes --127 degrees F with an exposure time of one (1) minute --133 degrees F with exposure time of 15 seconds, and --140 degrees F with an exposure time of 5 seconds, noting [MEDICAL CONDITION] occur even at water temperatures below these levels depending on the exposed individual's condition and length of exposure. 3. Review of Six (6) Months of Water Temperatures At 6:00 p.m. on 02/08/17, review of the facility's Daily Check Form for the previous six (6) months, revealed the following notable high water temperatures: -- 06/17/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/20/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/22/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/23/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/27/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/28/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/01/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/05/16 - room [ROOM NUMBER] - water temperature - 126 F -- 07/06/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/07/16 - room [ROOM NUMBER] - water temperature - 121.2 F -- 07/08/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/12/16 - room [ROOM NUMBER] - water temperature - 122 F -- 07/18/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/19/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 132.8 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 129.9 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/22/16 - room [ROOM NUMBER] - water temperature - 126.2 F -- 07/25/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/27/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/02/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 08/04/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/05/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/18/16 - room [ROOM NUMBER] - water temperature - 139.1 F -- 08/19/16 - room [ROOM NUMBER] - water temperature - 123.3 F -- 08/22/16 - room [ROOM NUMBER] - water temperature - 128.2 F -- 08/23/16 - room [ROOM NUMBER] - water temperature - 126.4 F -- 08/24/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/26/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 08/31/16 - room [ROOM NUMBER] - water temperature - 123.1 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 09/01/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/02/16 - room [ROOM NUMBER] - water temperature - 121.7 F -- 09/06/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/07/16- room [ROOM NUMBER]-water temperature - 123.6 F -- 09/07/16 - Shower Room A - water temperature - 120.3 F -- 09/08/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 134.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 123.5 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 138.6 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 122.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 122.6 F -- 09/14/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 120.2 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 121.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 122.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 123 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 123.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 138.5 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 133.4 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 125.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 124.7 F -- 09/23/16 - room [ROOM NUMBER] - water temperature - 133.7 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 137.4 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 129.4 F -- 09/27/16 - room [ROOM NUMBER] - water temperature - 130.9 F -- 09/28/16 - room [ROOM NUMBER] - water temperature - 136.3 F -- 09/29/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/30/16 - room [ROOM NUMBER] - water temperature - 131.3 F -- 10/04/16 - room [ROOM NUMBER] - water temperature - 125.4 F -- 10/06/16 - room [ROOM NUMBER] - water temperature - 122.4 F -- 10/07/16 - room [ROOM NUMBER] - water temperature - 136.5 F -- 10/10/16 - room [ROOM NUMBER] - water temperature - 131.9 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 137.8 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 10/13/16 - room [ROOM NUMBER] - water temperature - 126.9 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 134.0 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 127.5 F -- 10/17/16 - room [ROOM NUMBER] - water temperature - 135.8 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 129.2 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 120.5 F -- 10/21/16 - room [ROOM NUMBER] - water temperature - 121.9 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 121.8 F -- 10/25/16 - room [ROOM NUMBER] - water temperature - 127.4 F -- 10/26/16 - room [ROOM NUMBER] - water temperature - 128.5 F -- 10/27/16 - room [ROOM NUMBER] - water temperature - 123.7 F -- 11/01/16 - room [ROOM NUMBER] - water temperature - 122.9 F (After (MONTH) (YEAR), water temperatures were measured using the laser thermometer. Because the laser thermometer can be affected by a number of variables, the temperatures were questionable.) The facility had hot water temperatures in excess of 120 degrees F weekly since 06/17/16. On 02/09/17 at 11:15 a.m., when asked about the elevated temperatures recorded on the log, the administrator said, The maintenance department supervisor reviews those water temperatures daily and adjusts the temperature as needed. The facility provided no evidence to support the water temperatures were adjusted or that water temperatures were retaken after adjustments to ensure the adjustments were effective. The facility provided no other information to indicate other measures were implemented in an effort to ensure safe water temperatures despite the continuing problem. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. The identified residents were #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95, and #81. These findings were determined to constitute an immediate jeopardy (IJ) to the health and well-being of more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. b) Environment 1. Dining room a. Observation of the main dining room (used for food service and activities) with the Housekeeper/Laundry/Maintenance supervisor, Employee #73, began at 8:10 a.m. on 02/09/17. The following items were found: -- Debris behind the door leading into the dining room. -- The floor around the baseboards was dirty. -- The baseboards were splashed with debris. -- The wall, above the heater had cracked plaster. -- The door frames leading into the dining room were rusted and scraped. -- Trash, straws, napkins and paper products were littered behind the trash can. -- The floors were dirty in the alcove beside the ice machine. -- The floor had the remains of strips of tape which appeared to once be an outline of a shuffle board. --The tape had collected hair, lint and other debris. Employee #73 said the tape could be scraped from the floor, it just needed cleaned. -- The ice cart was splashed with dirt and debris. 2. Main Dinning Room On 02/06/17 at 11:40 a.m., observations of lunch in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/06/217 at 4:42 p.m., residents were seated for dinner at tables in the main dining room. The dining room floor was soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 7:51 a.m., observations of residents served breakfast in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 9:27 a.m., Staff #84 was mopping the main dining room floor. Staff #84 stated the floor should be mopped three times a day, and it had a lot of coffee and juice stains, and wheelchair marks. On 02/07/17 at 9:31 a.m., Staff #94 stated the main dining room floor es supposed to be cleaned after every meal. 3. Resident rooms Observations during the tour of the facility with the administrator began at 3:20 p.m. on 02/08/17. The following observations were made: -- room [ROOM NUMBER] - The light beside bed A had a cotton cord used to turn on the light over the bed was soiled. The floor tile was cracked in the corner beside bed-[NAME] -- room [ROOM NUMBER] - The plaster was missing at the corner of the closet. The corner behind the entrance door was littered with cob webs and dirt and debris. A wash pan and brief were found on the closet floor. The tile was stained around the commode. The plaster was cracked beside the toilet. Debris was found in the heater. -- room [ROOM NUMBER] - The floor tile of the room was cracked. The crack extended out the doorway and into the main hallway. The door facing, leading into the bathroom was rusted. The tile was chipped with holes beside bed-[NAME] -- room [ROOM NUMBER] - The wall was patched, but not painted under the bed-B window. Debris and dirt were found along the cove molding in the bathroom. -- room [ROOM NUMBER] - The wall beside the closet was marred and scratched. The over-the-bed table was rusted. The veneer on the table top was chipped and cracked. The wooden drawers beside the sink were scratched, marred, and water marked. The door facing, leading into the room was rusted. Upon entrance to the room the bed sheets were soiled with a runny brown/yellow substance on the top sheet of the bed. The administrator changed the sheets on the bed when found. -- room [ROOM NUMBER] - The over-bed table for bed A had rusted legs and splashes of dried debris on the legs. Debris was present along the baseboard in the bathroom. The tile under the sink was cracked. The wall beside the sink was marred and scratched. During the tour, the resident in the bed-B, said the crank at the foot of the bed was missing, making it impossible to raise the head of her bed. The administrator said she would get someone to fix the bed. (Observation found the bed cranking handle was missing from the bed.) There was also a round jagged hole in the resident's footboard at least the size of a fifty-cent piece. The door frame leading into the bathroom was rusted. -- room [ROOM NUMBER] - The walls were scratched with drywall exposed. The dresser drawers beside the sink were scratched and marred with chunks of wood missing. The sink top was discolored and had places of the finish missing. The tile beside the sink was broken. The cove molding and the area on the floor around the cove molding was dirty and splashed with dried debris. The cove molding in the bathroom was dirty around the floor of the bathroom. Debris was able to be cleaned from the cove molding with a piece of wet toilet paper. -- room [ROOM NUMBER] - Debris was found in the wall unit heating and air conditioner. The floor was dirty. The bathroom walls were scraped and marred with missing plaster. -- room [ROOM NUMBER] - A large head of a screw was sticking up out of the floor beside the sink with a broken piece of metal remaining under the screw. The administrator said this was a broken doorstop. The finish on the drywall in the bathroom (above the cove molding behind the toilet) was missing. At 8:10 a.m., on 02/09/17, the remaining tour of the facility resident rooms was conducted with Housekeeping/Laundry/ Maintenance Supervisor #73. -- room [ROOM NUMBER] - The sink was stained and the water from the facet was dripping. The dresser beside the sink was water marked, with the varnish missing, scraped, and marred. The finish on the countertop housing the sink was stained and the finish missing. -- room [ROOM NUMBER] - The door facings were rusted. The plaster beside the closet was marred and scraped. The over-the-bed table was dirty with debris splashed on the legs of the table. -- room [ROOM NUMBER] - The over-the-bed table at A-bed was rusted and dirty. -- room [ROOM NUMBER] - Observation found a dirty build up along the baseboards of the bathroom walls. The floor was dirty. The bed-A over-the-bed table, had legs which were rusted and dirty. -- room [ROOM NUMBER] - The over-the-bed table was rusted. The walls, beside the closet were scratched and marred with missing plaster. -- room [ROOM NUMBER] - The facing of the entrance door was rusted. A strong urine odor was present in the room. The arms of the resident's wheelchair were cracked with rough edges. -- room [ROOM NUMBER] - Observation found pieces of the tile under the sink were missing. The drawers beside the sink were marred, scratched and water marked. The wall beside the sink was marred and scratched. -- room [ROOM NUMBER] - The wall behind bed-A was scraped and scratched. There were holes in the tile beside the sink. Dirt and debris were found in the corner behind the door leading into the hallway. 4. Long hall shower room During the initial tour of the facility, observation of the long hall bathroom at 10:45 a.m. on 02/06/17, found a brown stain that appeared to be feces, on the seat of a shower chair in the bathroom. The director of nursing (DON) was present during this observation. She said she would have staff clean the shower chair. 5. A-Shower room The tour of the facility with Housekeeping/Laundry/Maintenance Supervisor #73 which began at 8:10 a.m., on 02/09/17 found the following issues in the shower room: -- Just inside the door of the shower were several large spots of a dried brown substance. Employee #73 identified the substance as feces. -- Two (2) pairs of gloves, turned inside out and rolled up, were in the sink. -- Several gloves littered the floor of the shower room. -- A dried brown substance was present on a shower chair. -- A comb and a bottle of bath wash were laying on the sink with no name to identify the owner. -- During Stage 1 of the Quality Indicator Survey a confidential interview with a resident found she did not want to take showers in the shower rooms on this floor because of the filth. She said the shower room should be called the, poop room, because everyone just pooped in there. She said it would be on the walls and in the floor of the shower room. She said she only showers in the upstairs shower room, Where it is cleaner. Employee #73 verified no showers had been given in this shower room since the issues with the hot water identified on the evening of 02/08/17. She said, All showers are being given on the upper floor of the facility not affected by the mixing valve. 6. Day room beside the nurses' station Four (4) of the five (5) blinds covering the windows had slats that were broken and bent. The exit door was rusted and cracked leaving exposed jagged edges of metal. There was dirt and debris buildup along the baseboards of the room. 7. room [ROOM NUMBER] At 11:15 a.m. on 02/09/17, observation of the grab bar beside the toilet was made with Employee #73. With a slight touch of the hand, the grab bar was found to move away from the wall. c) Interview Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on 02/09/17 at 2:03 p.m., found the water temperatures were never taken to the QA&A committee meetings and the facility had addressed the environmental issues and had even hired a outside housekeeping consultant. | 2020-09-01 |
| 3289 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 550 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to ensure Resident #32 was treated with dignity and respect. Nurse Aide #5 (NA), turned her back to the resident and made grumbling sounds and moved shoulders in a rotating motion twice. This was true for one (1) of sixteen (16) residents reviewed for dignity and respect. Resident identifier: #32. Facility census: 46. Findings included: a) Resident #32 An observation on 04/02/18 at 11:30 AM revealed Resident #32 requested a wet paper towel to wash her hands prior to eating her meal from NA #5. NA #5 turned her back on Resident #5 and made a Blaha sound while moving her shoulders in a rotating motion. Resident #32 asked NA #5 for additional paper towels to dry her hands. NA #5 again with back turned from this resident, made the Blaha sound and made rotating motions with her shoulders. Resident #32, who was hard of hearing, did not hear or see NA #5. During an interview on 04/02/18 at 1:59 PM, the Director of Nursing agreed NA #5's actions were disrespectful to Resident #32. | 2020-09-01 |
| 3290 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 558 | E | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide services with reasonable accommodations for residents. A bathroom in the hallway near the activity room was available for resident use without a safety call light in working condition. This practice had the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) Observations on 04/04/18 at 10:50 AM, noted a resident using the bathroom near the activity room on the first floor. Observation of this bathroom found no pull string attached to the alarm which would alert staff to provide care if needed. At 3:33 PM on 04/04/18 Maintenance Staff #31 explained the bathroom was for staff and visitors, but was told not to disallow residents to use the bathroom. On 04/04/18 at 3:35 PM, the maintenance supervisor verbalized the residents did use that bathroom. The switch in which a pull string could be attached was tested by the maintenance supervisor and would not work. The bathroom door knob was replaced with a key entry to prevent residents from using the bathroom. | 2020-09-01 |
| 3291 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 561 | D | 0 | 1 | NWDF11 | Based on observations, resident interview, staff interview, and record review, the facility failed to provide a resident with her diet of choice. This is true for one (1) of sixteen (16) residents reviewed. Resident identifier: #1. Facility census: 46. Findings include: a) Resident #1 During the initial tour on 04/02/18 at 11:55 AM, observation of Resident #1's lunch tray found it did not include cranberry juice. The tray ticket noted cranberry juice should be on the tray. Resident #1 stated she requested cranberry juice, but I don't often get it. Observation of the lunch tray on 04/03/18 at 12:15 PM, again revealed there was no cranberry juice on the resident's tray. Resident commented, I did have it Sunday. Again on 04/04/18 at 11:45 AM, Resident #1's lunch tray had no cranberry juice. The tray ticket also listed coffee as a request. Resident #1 stated she also did not get coffee on this date, and went on to state she does not make the facility aware of food that is not on her tray unless she does not have chicken noodle soup. On 04/04/18 at 3:10 PM, the dietary manager explained the trays had been checked by dietary staff as food was put on the trays and the cranberry juice should have been on the resident's lunch tray. | 2020-09-01 |
| 3292 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 578 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure a resident's code status was accurate, available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy in the resident's medical record. This failed practice was true for one (1) 16 residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the paper medical record on 04/03/18 found conflicting orders for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: --State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 --the Physician order [REDACTED]. --the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; --admission orders [REDACTED] --physician's orders [REDACTED]. --physician's orders [REDACTED]. --admission orders [REDACTED] --Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nurse Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. NAs #46 and #84, and LPN #72, stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that showed DNR. During an interview on 04/04/18 at 2:40 PM, when asked how she knew the code status of a resident. LPN replied, We don't exchange that in report unless there was a change in status because they all know their residents. When asked to show the code status for Resident #18, LPN #72 pointed to the computer screen which displayed DNR. On 04/04/18 at 3:20 PM, Registered Nurse (RN) #44 looked on the hard copy medical record for Resident #18 and stated that she was a full code. Further review of the hard copy medical record with RN #44 found evidence of both DNR and FULL CODE status. RN #44 looked on the desktop computer and found the code status for Resident #18 was DNR. During an interview on 04/04/18 at 4:00 PM, the Director of Nursing (DoN) stated Social Worker (SW) #3 had found a POST form that the Resident #18 signed in 2004 requesting a to be a full code, but the MPOA had changed the code status to a DNR. DoN stated that she felt like the MPOA changed the code status without the consent of Resident #18. The DoN stated that she was not aware that the chart had conflicting code status orders and that the electronic chart code status was incorrect. The DON agreed this was confusing for the staff and the charts both electronic and the hard copy were wrong. | 2020-09-01 |
| 3293 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 584 | E | 0 | 1 | NWDF11 | Based on observation, resident interview, and staff interview, the facility failed to maintain a comfortable and homelike environment for three (3) of sixteen (16) sampled residents. There were holes in the fitted sheet on Resident #21's bed. Residents #32 and #19 felt the water temperature during showers was too cool. Resident identifiers: #32, #19, and #21. Facility census: 46. Findings included: a) Resident #21 On 04/04/18 at 4:46 PM, an observation of the fitted sheet on Resident #21's bed revealed the sheet had holes. After showing the sheet to Nurse Aide (NA) #46 and NA #16, they changed the sheet. On 04/04/18 at 5:03 PM, an observation with Licensed Practical Nurse (LPN) #72 revealed the sheet NA #46 and NA #16 put on the bed also had holes. LPN #72 said the facility expected staff to discard linens with holes. b) Resident #19 On 04/02/18 at 4:02 PM, an interview with Resident #19 revealed she often got a shower where the water was too cold, and there did not ever seem be enough hot water. The resident said a nurse aid (could not remember the name) told her the maintenance said she was taking a shower at the wrong time of day because the kitchen used the water for dishes. The resident said the ombudsman even came into the facility and met with the administrator about the cold showers and other issues. When asked about the result of the meeting, the resident said, The administrator said that it takes too long for me to take a shower. I now have a designated time to take a shower, but sometimes the water still gets cold. c) Resident #32 During an interview on 04/02/18 at 11:34 AM, Resident #32 stated while getting a shower the water was too cold. On 04/02/18 at 01:40 PM, in Shower Room A, Nursing Aide (NA) #54 was assisting with checking water temperatures. NA #54 said, It takes a while for the water to heat up. After running the shower for 10 minutes, the water temperature for the left shower reached 96 degrees Fahrenheit (F) and the shower on the right reached 88 degrees F. On 04/02/18 at 1:55 PM, the Director of Nursing (DoN) was informed of the shower water temperatures in Shower Room [NAME] On 04/03/18 at 3:00 PM, in the presence of another surveyor, Life Safety surveyors, and the Maintenance Director, the water temperature in the left shower in Shower Room B was 88 degrees and 78 degrees F in the right shower after running the water for seven (7) minutes. | 2020-09-01 |
| 3294 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 623 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) resident who was discharged to the community received a discharge notice. Resident #40 left the faciity on therapeutic leave and did not return. The facility discharged him, but did not ensure he received a notice. This affected one (1) of two (2) residents reviewed for discharge notices. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his cousins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left the faciity on [DATE] and did not return. The SW said the facility did not issue a discharge notice to this resident because he did not return, and he basically discharged himself. During this same time, the administrator said after 30 days had passed the facility considered the resident discharged . The administrator also felt the facility had no obligation to issue a discharge notice to the resident because he went on leave and did not return. | 2020-09-01 |
| 3295 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 625 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident who left the building on therapeutic leave received written notice of the facility's bed-hold policy. Although the resident did not return to the facility, there was no evidence the facility attempted to provide its bed-hold policy to the resident. This was found for one (1) of one (1) resident reviewed for notice of the facility's bed-hold policy when going on therapeutic leave. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW) and the administrator on 04/04/08 at 5:30 PM the administrator said the resident did not receive a bed-hold notice. The administrator felt because of the manner in which the resident left, the facility had no obligation to provide a bed-hold notice. No further information was provided. | 2020-09-01 |
| 3296 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 641 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review, staff interview, policy review the facility failed to ensure accurate assessments were completed for one (1) of 16 residents. Resident #40's assessment did not have an accurate assessment related to discharge. Resident identifier: #40. Facility census: 46. Findings include: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daught of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medicaitons for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left the faciity on [DATE] and did not return. The facility completed a prosepective payment system (PPS) 5 day Minimum Data Set (MDS) assessment for Resident #40 on 02/16/18. During an interview with Registered Nurse (RN) #43, on 04/04/18 at 9:07 AM, the RN said the facility had not completed a discharge assessment for Resident #40. | 2020-09-01 |
| 3297 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 655 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement an accurate baseline care plan for Resident #98. The resident's baseline care plan did not include fall risk or care for a wound on the foot, both present at the time of admission. This was true for one (1) of sixteen (16) records reviewed. Resident identifier: #98. Facility census: 46. Findings included: a) Resident #98 Medical records review revealed Resident #98 was admitted to the facility on [DATE]. Review of discharge summary from the hospital where Resident #98 was treated prior to being admitted to the facility, revealed the reason for admission to the hospital was a subtrochanteric fracture (a [MEDICAL CONDITION] bone near the hip) of left hip on 03/03/18. Review of the baseline care plan, with a date of 03/16/18, was absent of any evidence Resident #98 had a risk for falls. physician's orders [REDACTED]. Review of nursing admission assessment with a date of 03/17/18 revealed Resident #98, .was admitted to (initials) Nursing after sustaining a fall in previous nursing home facility. The fall evaluation completed on admission also revealed a high fall risk. Fall risk was not included in the base line care plan. The nursing assessment dated [DATE] identified Resident #98 had a, blister like area on the left heel that has a protective dressing intact. The baseline care plan with a date of 03/16/18 did not include actual skin breakdown or treatment for [REDACTED]. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed indicating full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed, the resident's risk of falls and the wound observation on the nursing admission were not identified on the baseline care plan. | 2020-09-01 |
| 3298 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 656 | D | 0 | 1 | NWDF11 | Based on record review and staff interview, the facility failed to develop a care plan for care of an indwelling catheter when Resident #18 returned to the facility with an indwelling catheter. This affected one (1) of sixteen (16) from the sample. Facility census: 46. Finding included: a) Resident #18 On 04/02/18 a record review revealed Resident #18 returned to the facility from a local hospital with an indwelling Foley catheter on 03/30/18. The indwelling catheter was not care planned at that time. On review of records on 04/03/18 a care plan was on record showed a date created on 04/03/18. The indwelling catheter was not care planned for four (4 ) days. On 04/02/18 at 4:30 PM, the Director of Nursing (DoN) was asked for a paper copy of the care plan. On 04/03/18 at 4:45 PM, DoN the DoN provided a paper copy of the resident's care plan. At that time, the DoN was informed no care plan was developed for the indwelling catheter until four (4) days after Resident #18 returned from the hospital. | 2020-09-01 |
| 3299 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 677 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide care and services to maintain good grooming/personal hygiene to one (1) randomly observed resident. Resident #12's fingernails were long and jagged. Several of the resident's fingernails also had a black/brown substance underneath them. Resident identifier: #12. Facility census: 46. Findings included: a) Resident #12 On 04/04/18 at 5:13 PM, an observation of Resident #40's nails revealed they were long, jagged, and had a brown/black substance underneath them. Licensed Practical Nurse (LPN) #72 observed Resident #40's nails on 04/04/18 at 5:20 PM and said she would trim and clean them. On 04/05/18 at 8:12 AM LPN #72 said it took her several times of going back to the resident, but she did get them trimmed and cleaned. On 04/05/18 at 11:00 AM, the administrator and director of nursing said the resident was resistant to care. His care plan revealed he did not like to be shaved and would often wear dirty clothing. The minimum data set (MDS) completed on 01/15/18 reflected the resident needed extensive assistance with personal hygiene. A review of the progress notes revealed a note dated 02/13/18 by Registered Nurse (RN) #43. The note stated the resident allowed his nails trimmed without difficulty, but did not want them cleaned. No further notes showed follow up attempts to clean the resident's nails. | 2020-09-01 |
| 3300 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 686 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and staff interview, the facility failed to identify and provide care related to Pressure Ulcers. Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. In addition, the facility failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. These failed practices were true for two (2) of four (4) residents reviewed for pressure ulcers. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs. b) Resident #98 Review of the admission nursing assessment dated [DATE] revealed Resident #98 had a blister like area on the left heel that has a protective dressing intact. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed the wound identified on 03/17/18 did not receive medical interventions until 03/19/18. | 2020-09-01 |
| 3301 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 690 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation and staff interview, the facility failed to provide care in accordance with its policy and physician orders, regarding securing an indwelling catheter. A random observation of Resident #18 noted no device to secure the resident's catheter was in place. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Catheter Care, with a reviewed date of (MONTH) 207, found it included that a leg strap must be used to prevent accidental injury and/or removal. An observation of wound care for Resident #18 on 04/03/18 at 3:00 PM, found this resident had an indwelling urinary catheter (Foley catheter). Further observation revealed the catheter was not secured to prevent accidental removal or to reduce the risk of trauma. This was verified with Registered Nurse #44 and Licensed Practical Nurse #39, who agreed the resident should have a stabilization method for the catheter. The physician's orders [REDACTED]. | 2020-09-01 |
| 3302 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 692 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to provide therapeutic diets in accordance with physician orders [REDACTED].#25. Both residents received foods that were not of the correct consistency. This was true for two (2) of seven (7) residents reviewed for the care area of Nutrition/Hydration Status. This practice had the potential to affect a limited number of residents. Resident identifiers: #22 and #25. Facility census: 46 Findings included: a) Resident #22 Review of records revealed Resident #22 had a [MEDICAL CONDITION] (TBI), was a quadriplegic (one affected with partial or complete paralysis of both the arms and legs), had [MEDICAL CONDITION] (an inability to comprehend and formulate language because of damage to specific brain regions). Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/18, at 09:58 AM on 04/05/18, revealed the resident's Brief Interview for Mental Status (BIMS) score was zero (0), indicating the resident was severely cognitively impaired. The resident was assessed as totally dependent with all activities of daily living (ADLs). Medical record review found Resident #22 had a swallowing disorder that was demonstrated by loss of liquids and solids from his mouth when eating or drinking, and coughing or choking during meals. The resident required a mechanically altered diet that required change in the texture of food and liquids (pureed food and thickened liquids). The physician's orders [REDACTED]. Diet order puree with honey thickened liquids. Observations on 04/03/18 at 11:49 AM, revealed a bowl of thin tomato soup on the resident's lunch tray. Nurse aide (NA) #34 was preparing to feed the resident his lunch. According to the resident's lunch ticket, the resident was to receive pureed vegetable soup honey consistency. When asked what was in the bowl sitting in front of the resident, NA#34 said it looked like tomato soup. Speech Therapist #100 was at another table assisting a resident and turned quickly around and told NA#34, He (Resident #22) can't have that he will choke. Speech Therapist #100 came over and removed the bowl. Interview with Speech Therapist #100, on 04/05/18 at 10:27 AM, revealed she started working at the facility in (MONTH) (YEAR) and had worked with the resident. She said she mostly worked with the resident to help him with positioning because he was at risk for aspiration, and that he could not have anything thin because he was an aspiration risk and would get choked. Speech Therapist #100 said the resident would have hard fits of coughing and choking if not given at least honey thick consistency. Speech Therapist #100 said, The other day (on 04/03/18 at 11:49 AM) I heard you (this surveyor) ask the NA (NA#34) what was in the bowl. That's why when I turned around and I saw the bowl of tomato soup, I spoke out. It's too thin. He can't have that, he gets choked. b) Resident #25 Review of physician orders [REDACTED].#25 was prescribed a regular liberalized diet mechanical soft. On 04/04/18 at 11:50 AM, Resident #25's lunch meal ticket revealed the resident should have shredded lettuce. Observation of the meal tray revealed the lettuce was not shredded, but was in larger pieces. At 3:08 PM the dietary manager agreed the lettuce should be shredded. | 2020-09-01 |
| 3303 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 710 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility Physician failed to evaluate and assess medical issues related to the residents skin status for one (1) of four (4) in the care area Pressure Ulcers. Resident identifier #18. Facility census 46. Findings included: a) Resident #18 Review of records revealed Resident #18 was readmitted on [DATE]. There was no mention or description of any pressure ulcers until 04/2/18. During an interview on 04/05/18 at 9:08 AM, Resident #18's physician he stated he had not looked at the pressure ulcers on Resident #18. He stated, that was on him, because he took the nurses' charting and notes at face value and failed to look at the resident himself. He also agreed that the nursing documentation was not consistent or accurate. The progress note he wrote on 04/04/18, reinforced his statement that he had not examined this resident himself. | 2020-09-01 |
| 3304 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 726 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, staff interview, and family interview the facility failed to have nursing staff with the appropriate competencies and skills set to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Pressure ulcers Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. The facility failed to ensure Resident #18's pressure areas were assessed and when assessed, that they were assessed correctly and timely, and failed to implement timely interventions. The facility also failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. 1. Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs. 2. Resident #98 Review of the admission nursing assessment dated [DATE] revealed Resident #98 had a blister like area on the left heel that has a protective dressing intact. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed the wound identified on 03/17/18 did not receive medical interventions until 03/19/18. b) The facility failed to develop and implement an accurate baseline care plan for Resident #98. The resident's baseline care plan did not include fall risk or care for a wound on the foot, both present at the time of admission. 1. Resident #98 Medical records review revealed Resident #98 was admitted to the facility on [DATE]. Review of discharge summary from the hospital where Resident #98 was treated prior to being admitted to the facility, revealed the reason for admission to the hospital was a subtrochanteric fracture (a [MEDICAL CONDITION] bone near the hip) of left hip on 03/03/18. Review of the baseline care plan, with a date of 03/16/18, was absent of any evidence Resident #98 had a risk for falls. physician's orders [REDACTED]. Review of nursing admission assessment with a date of 03/17/18 revealed Resident #98, .was admitted to (initials) Nursing after sustaining a fall in previous nursing home facility. The fall evaluation completed on admission also revealed a high fall risk. Fall risk was not included in the base line care plan. The nursing assessment dated [DATE] identified Resident #98 had a, blister like area on the left heel that has a protective dressing intact. The baseline care plan with a date of 03/16/18 did not include actual skin breakdown or treatment for [REDACTED]. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed indicating full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed, the resident's risk of falls and the wound observation on the nursing admission were not identified on the baseline care plan. | 2020-09-01 |
| 3305 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 761 | E | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy and procedures review, the facility failed to adequately store and dispose of expired medications. Nine (9) oral medications and three (3) vials 0.9% Sodium Chloride Irrigation were not returned to the pharmacy and/or destroyed in a timely manner as per pharmacy policy and procedure. Additionally, the facility failed to ensure all prescription medications were labeled. This practice had the potential to affect more than an isolated number of residents. Findings includes: a) On 04/03/18 at 09:43 AM, Licensed Practical Nurses (LPNs) #39 and #42 were present during the inspection of the facility's medication room and the long hall medication cart. When asked, neither LPN could explain the facility's policy and/or process for identifying a medication's expiration date, or the record keeping and disposing of expired medications. The facility's stock medications included those labeled and dispensed by (name of pharmacy) as well as two (2) stock medications, which were not labeled. The medications dispensed by the pharmacy included the medication's expiration date on each label: 1. Therems-M (Multivitamin with iron and other minerals): expiration date 11/17/17 2. Vitamin C 500 mg: expiration date 01/23/18 3. [MEDICATION NAME] Coated ASA 81 mg: expiration date 11/17/17 4. Zinc Sulfate 200 mg (50 mg): expiration date 11/29/17 5. ASA 81 mg Chewable: expiration date 01/23/18 6. ASA 325 mg: expiration date 02/08/18 7. [MEDICATION NAME][MEDICATION NAME] 25 mg: expiration date 01/06/18 8. [MEDICATION NAME]-HC 25 mg suppositories: expiration date 04/2018 (no pharmacy label) 9. Fast Acting Mi-Acid Regular Strength Antacid/[MEDICATION NAME] Original: expiration 1/18 (January (YEAR)) 10. 0.9% Sodium Chloride Irrigation, USP 3 vials: expiration date 03/06/18 During the inspection of the medication cart, two (2) unlabeled medications, [MEDICATION NAME] 2.5 mcg (micrograms) (Opened 2/12/18) and [MEDICATION NAME] 160/4.5 (Opened 2/12/18), were discovered. LPN #42 stated, Those inhalers are for (name of Resident #46). When asked why the medications were not labeled, LPN #42 stated, I don't know why they aren't labeled. On 04/03/18 at 10:45 AM, the DON brought the large bottle of Therems-M (Multivitamin with iron and other minerals) with an expiration date of 11/17/17. She stated, We do not follow the expiration date that the Pharmacy puts on the label. We follow the actual original expiration date that is on the bottles When asked her if she was aware that the majority of the pharmacy labels were actually placed over the distributor's expiration dates, and were illegible, she replied, Yes. When asked what did they did in those cases, she had no reply other than, I'm going to ask the Pharmacy to stop sending us these large bottles of stock medications. Review of the requested facility's policies regarding medications, including storage & the protocol regarding returning medications and/or destroying medications discontinued medications, and/or a resident was discharged found the following: -- The Administering Medications policy, updated (MONTH) 1, (YEAR) and effective (MONTH) 16, (YEAR), included, 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. -- The policy did not address the protocol regarding returning medications and/or destroying medications after a medication was discontinued and/or the resident was discharged . During an interview on 04/05/18 at 11:45 AM, the DON stated, The two (2) inhalers came with (Resident #46's name) when she was discharged from (name of acute care hospital) and readmitted to here. Neither the [MEDICATION NAME] or [MEDICATION NAME] were labeled. They have been disposed of, and new ones have been ordered from the pharmacy. | 2020-09-01 |
| 3306 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 838 | E | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility assessment, medical record review and staff interview the facility failed to ensure they conducted a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. Nursing staff did not receive training that equipped them with the competencies necessary to provide the level of care needed by the residents. Resident #18 did not receive care and treatment necessary for the prevention of and treatment for [REDACTED].#18. Facility census: 46. Findings include: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs. | 2020-09-01 |
| 3307 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 842 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure the accuracy of a resident's code status, and to ensure it was readily available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy of the medical record. This failed practice was true for one (1) of sixteen (16) residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the hard copy (paper) medical record conflicting orders were found on 04/3/18 for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: - State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 - the Physician order [REDACTED]. - the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; - admission orders [REDACTED] - physician's orders [REDACTED]. - physician's orders [REDACTED]. - admission orders [REDACTED] - Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nursing Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. The NAs and LPN stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that showed DNR. During an interview on 04/04/18 at 2:40 PM, when asked how she knew the code status of a resident, LPN #72 replied, We don't exchange that in report unless there was a change in status because they all know their residents. When asked to show the code status for Resident #18, LPN #72 pointed to the computer screen which displayed DNR. On 04/04/18 at 3:20 PM, Registered Nurse (RN) #44 looked on the hard copy medical record for Resident #18 and stated that she was a full code. Further review of the hard copy medical record with RN #44 found evidence of both DNR and FULL CODE status. RN #44 looked on the Desk Top Computer and found the code status for Resident 18 was DNR. During an interview on 04/04/18 at 4:00 PM, the Director of Nursing (DoN) stated that Social Worker (SW) #3 had found a POST form that the Resident #18 signed in 2004 requesting to be a full code, but the MPOA had changed the code status to a DNR. The DoN stated that she felt like the MPOA changed the code status without the consent of Resident #18. The DoN stated that she was not aware that the chart had conflicting code status orders and that the electronic chart code status was incorrect. The DON agreed this was confusing for the staff and the charts both electronic and the hard copy were wrong. | 2020-09-01 |
| 3308 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 880 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of diseases and infection to the extent possible. During random observations, Resident #98's nasal cannula tubing was laying inside a garbage can and Resident #32's nebulizer mouthpiece was lying unprotected on the floor. Resident identifiers: #98 and #32. Facility census: 46. Findings included: a) Resident #98 Observations at 11:12 AM on 04/04/18 found Resident #98's nasal cannula tubing laying in a garbage can. The tubing was still attached to the oxygen concentrator and the was concentrator running. Nursing assistant #66 explained I was in a hurry, and put it in the garbage can because it had bowel movement on it. Because of being in a hurry the tubing was not detached from the oxygen concentrator. At 11:30 AM on 04/04/18, the director of nursing (DON) observed the tubing in the garbage can and agreed it should have been detached from the concentrator. b) Resident #32 An observation on 04/02/18 at 11:19 AM, revealed the resident's nebulizer mouth piece (used to administer breathing treatments) lying unprotected on the floor. This finding was verified with Nurse Aide #5 and Licensed Practical Nurse (LPN) #42. During an interview on 04/02/18 at 11:26 AM, LPN #42 agreed the nebulizer mouth piece should have been stored in a clean bag. | 2020-09-01 |
| 3309 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 921 | E | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide a safe environment for residents. A container of disinfectant wipes were left unsecured on the back of a commode in shower room B. This practice has the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) At 11:55 AM on 04/02/18, during the initial tour of the facility, the unlocked shower room B was found to have a container of disinfectant wipes sitting on the commode tank. The safety data sheet (SDS) for this disinfectant included a warning about acute toxicity for eye contact and skin contact. Eye contact first aid should include, immediately flushing the eye with large amounts of water. Skin contact first aid includes immediately flush skin with plenty of water while removing clothing. At 3:00 PM on 04/02/18, the disinfectant wipes remained on the commode tank in shower room B and the facility administrator entered the room and removed the disinfectant wipes. At 9:00 AM on 04/05/18, the facility administrator agreed the disinfectant wipes should not have been in shower room B where residents had easy access. | 2020-09-01 |
| 3310 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 574 | E | 0 | 1 | KGJN11 | Based on Resident Council meeting and observation, the facility failed to display the Resident Rights poster easily accessible to all residents wanting to review these rights. This was reported during the Resident Council meeting regarding the posters being too high for residents in wheelchairs to review. This had the potential to affect all residents wishing to review their Resident Rights from a seated position. Facility census: 57. Findings included: a) Resident Rights poster During a Resident Council meeting on 04/09/19 at 11:45 AM, this group of residents reported the Resident Rights poster located on the wall by the Dining Room and on 100 Hallway were too high for any residents in a wheel chair to be able to read. An observation on 04/09/19 at 12:15 PM of the Resident Rights posters located on the wall by the Dining Room and the 100 hallway could be lowered to be more accessible to any residents in a wheel chair. In an interview with the Interim Nursing Home Administrator on 04/09/19 at 12:45 PM, was informed of the Resident Council concern regarding the height of the Resident Rights poster being displayed too high for residents in a wheel chair to review. | 2020-09-01 |
| 3311 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 600 | K | 0 | 1 | KGJN11 | Based on observation, record review, resident interview and staff interview, the facility failed to ensure Resident #33 was free from neglect. Resident #33 went 9 and 16 days without a shower. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #33. Facility census: 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a reportable concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit. b) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN was asked to verify the Resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey. | 2020-09-01 |
| 3312 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 607 | E | 0 | 1 | KGJN12 | Based on record review, policy review and staff interview the facility failed to implement their Abuse Policy as it pertained to the reporting and investigating of allegations of abuse. This practice has the potential to effect all residents currently residing in the facility. Resident #13 on multiple occasions was sexually abusive toward six (6) different female residents. These allegations were not reported and/or investigated thoroughly as directed by the facility's policy. Resident identifiers: #13, #55, #40, #2, #25, #61 and #15. Facility census: 56 Findings Include: a) Resident #13 A review of the reportable incidents from 05/29/19 through current found an Immediate Fax Reporting of allegations - Nursing Home Program. This form was completed by the facility's social worker on 06/04/19 and faxed to the Office Health Facility Licensure and Certification (OHFLAC) on 06/04/19 at 1:25 p.m. The date of the incident was listed as 06/03/19 and the brief description of the incident read as follows, (First and Last name of Resident #13), resident at the (Name of facility), approached 3 female residents trying to rub his private area against them and put his penis in their mouth. Staff immediately intervened and diffused the situation. Review of the Five Day follow up form found the following under the section titled outcome/results of investigation: (First and Last name of Resident #13), resident at the (Name of Nursing Facility) approached 3 female resident trying to rub private area against them and put his penis in their mouth. Staff intervened immediately and diffused the situations. Families were notified of the incident. Under the section Corrective Action by the facility the following was noted, (First and Last name of Resident #13) was sent out of facility for psychiatric treatment/evaluation. Addressed behavior in care plan to avoid any further incidences. Resident will be assessed upon return for mental status and any further behaviors. A review of the investigation or this incident found only one statement from a staff member attached. This statement was from the receptionist who works in Human Resources Employee #54 about an incident which took place on 06/04/19 at 7:23 a.m. it read as follows, I was buzzed into the building and went to clock in. When I rounded the corner after clocking in, I saw Mr. (Last name of Resident #13) grabbing (First Initial and last name of Resident #55)'s wheel chair and turning it to face him. He then stood up, reached his hand down his elastic panty and showed Ms. (Last name of Resident #55) his penis. I said very firmly Stop. Mr. (Last name of Resident #13) only laughed. I told Mr. (Last name of Resident #13) I don't think it's funny at all to which he responded. I think it's real funny! and continued to laugh. Ms. (Last name of Resident #55) had wheeled away from him by then and I went down the hall to immediately report what I had seen to the [MI]P.N. (Licensed Practical Nurse) at the desk (First and last name of LPN #7). (First and last name of LPN #91) contacted my office a few minutes later and asked me to write a statement. This statement was in regards to an incident that happened 06/04/19 which was not the incident that was reported for 06/03/19. No other statements were attached to this investigation. An interview with the NHA at 1:36 p.m. on 07/23/19 confirmed the statement attached to this investigation was for a different incident and there were no other statements attached and/or obtained in regards to the incident on 06/03/19. A review of Resident #13's medical record at 1:00 p.m. on 07/22/19 found the following pertinent nursing progress notes, -This note was entered as a late entry for a date of 06/03/19 at 4:35 p.m. (Recorded as Late Entry on 06/04/2019 11:41 AM) resident has been wandering up and down hallways and in and out of dining hall. sexually inappropriate behaviors x 3 noted by staff and residents. resident was noted to remove his penis from his pants and rubbing it on another res., face, also putting it in 2 residents mouth. he was approached quickly and re directed away from residents, and q 15 minutes watch was started. This note was written by LPN #82. -06/04/19 at 7:49 a.m. Resident was noted by (First Name of Employee #54) in HR to be exposing himself to a female resident. Resident was walked back to his room by staff. Notified (First and Last name of administrator), Administrator. Resident is to be transported to (Name of local hospital) for evaluation. MPOA notified and was in agreement. (Name of local rescue Squad) called for transport at 0739. Report called to (Name of local hospital) at 0739. VS 128/72 Temp 98.0 HR 78 Resp 18 O2 Sat 98% BRS arrived 0748. Resident transported out of facility at 0755 accompanied by 2 attendants. Please note a statement was not obtained from LPN #82 regarding this incident even though she must have had knowledge of what had happened. Also the nurses note clearly identify four (4) separate occurrences of sexual abuse. Three (3) on 06/03/19 which were reported on 06/04/19 outside of the required two (2) hour time frame and one (1) on 06/04/19 which was not reported at all. -06/19/19 at 12:46 p.m. Resident observed by staff displaying sexually inappropriate behaviors. Q15 minute checks initiated to monitor Resident. -06/20/19 at 4:47 p.m. Resident was walking back from dining room down short hall. CNA reported resident smacked her buttocks as he walked past. Q 15 minute checks in place. Will continue to monitor and observe. -06/20/19 at 5:53 p.m. Resident being transferred to (Name of Local hospital) via (Name of local rescue squad) for evaluation for admittance to (Name of Local Psychiatric Hospital). Resident has been noted by staff to be exhibiting inappropriate sexual behaviors to other residents and staff. (Name of local rescue squad) called at 1736. MPOA (First and last name of MPOA) called at 1737. No answer received. Message left informing of Resident's transfer and instructions to call facility with any questions. Report called to (First name of RN at local hospital), RN at (name of local hospital) ER at 1742. Behavioral observation completed. Transfer/Bed hold form completed and will be sent with resident in transfer packet. -06/28/19 at 12:30 p.m. Resident returned to facility at 1220 via (Name of local Rescue Squad) x 2 attendants. No complaints voiced. No signs symptoms distress noted. Resident shown to new room in (Room Number Redacted for confidently). Resident expressed understanding. VS BP 94/61 HR 68 Temp 98.4 Resp 18 O2 Sats 97%. Skin Assessment performed. Resident cooperative and agreeable. Will continue to monitor. -06/28/19 at 1:30 p.m. Resident observed by staff members exhibiting inappropriate sexual behaviors with other residents in residents room and dayroom. Staff intervened. RN notified. Resident being monitored closely at this time. -06/28/19 at 3:05 p.m. New order received to transfer resident as a direct admit to the (Name of Local Psychiatric Unit). Q 15 minute checks initiated. MPOA (first and last name of MPOA) notified and expressed understanding and agreement. (Name of local rescue squad) called for transport. Report called to (First and Last name of RN at local hospital), RN. (Name of local rescue squad) arrived 1507. VS 94/61 Temp 98.4 Resp 18 HR 68 Resident left facility by stretcher via (Name of local Rescue squad) x 3 attendants at 1507. At 2:00 p.m. on 07/22/19 the Nursing Home Administrator (NHA) was interviewed. When asked if the incident that took place on 06/19/19 and 06/28/19 were reported she indicated they had not been reported. She stated, We reported the first incident, but since he is confused and the victims were confused and they had sent him out they did not think the other incidents were reportable and did not report them. She stated, The residents did not know what was going on so we did not think we needed to report the additional incidents. At 2:20 p.m. on 07/22/19 the Social Worker joined the interview with the NHA, they were asked what the nursing note dated 06/19/19 was referring to. The note was not clear as to who the sexual inappropriate behaviors exhibited by Resident #13 on this date were directed toward. The Social Worker indicated it was Resident #25. When asked what Resident #13 had done to Resident #25 on this date the social worker stated, I think she told me he had just pulled his Junk (Junk is a slang term for a males penis and testicles) out. The social worker stated, I did a concern form about it but did not report it. A review of the concern forms found a form dated 06/20/19 which was completed by the Social Worker. The form was concerning Resident #25 and under the section titled, Describe grievance/compliant using factual terms: the following was hand written by the Social Worker, Resident Stated male resident was being sexually inappropriate (touched her face with penis). This was a one time occurrence. Male Resident is very confused. Under the section title, What other actions were taken to resolve grievance/compliant (be specific)? 15 minute checks were initiated; Resident is encouraged to stay in common areas of facility so staff can monitor the situation male resident was sent out of the facility for an evaluation on 06/21/19. The record also contained no further information regarding the incident on 06/28/19. There was no concern form completed nor a reportable and the victims for this incident were not identified prior to surveyor intervention. During a final Interview with the NHA and Social Worker at 1:36 p.m. on 07/23/19 the above findings were reviewed. The NHA stated we can see now that maybe we did not do enough. We thought that sending him out to the hospital would be enough but now we see that we did not do enough to keep the other residents safe. She agreed the incident on 06/03/19 though it was reported was not thoroughly investigated and the incidents on 06/04/19, 06/19/19 and 06/28/19 were not reported and/or thoroughly investigated. b) Policy Review A review of the facility's policy found the following pertinent information: . Definition of Abuse .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Implementation of Abuse policy and procedures 5. Investigation: All different types of incidents and complaints will be screened for possible sign of abuse. The complaint coordinator will be responsible Igor the initial reporting, investigation of alleged violations, and reporting results to the proper authorities . 7. Reporting/Response: All alleged violations and substantiated incidents will be reported to the state agency and to all other agencies as required, and depending on the results of the investigation, necessary corrective actions will be taken. The facility will report to the state nurse aide registry or licensing authorities any knowledge it has of any actions )by a court of law which would indicate and employee is unfit for service. The occurrences will be analyzed to determine what changed are needed, if any to policies and procedures to prevent further occurrences. | 2020-09-01 |
| 3313 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 609 | D | 0 | 1 | KGJN11 | Based on record review, resident interview and staff interview, the facility failed to report suspected abuse and neglect to the required state agencies. This failed practice had the potential to affect a limited number of residents. Resident identifier: #48. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a reportable concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit. | 2020-09-01 |
| 3314 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 610 | D | 0 | 1 | KGJN11 | Based on record review, resident interview and staff interview, the facility failed to investigate allegations of suspected abuse and neglect. Resident #48 reported an allegation of abuse and neglect and the facility failed to complete a thorough his was a random opportunity for discovery. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. The Grievance and Concern form did not note any protections put into place to safeguard the resident from the alleged perpetrator. The form did not mention any information concerning an investigation. A review of records revealed there was not an investigation completed by the facility for the allegation of verbal/mental abuse and neglect. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a investigation concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit. | 2020-09-01 |
| 3315 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 641 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete an accurate medium data set (MDS) assessment of one (1) of sixteen (16) MDS assessments reviewed during the investigation process of the survey. The Restraint section of the MDS assessment for R8 was not coded to include a wander/elopement alarm. Resident identifier: R9. Facility census: 57. Findings included: a) R9 During a medical record review on 04/08/19 of the comprehensive MDS assessment for R9 with an assessment reference date (ARD) of 01/14/19 revealed the section for Restraints and Alarms had not been coded to include the use of a wander/elopement alarm. Further review revealed a physician's orders [REDACTED]. In an interview on 04/09/19 at 11:15 AM with E74, registered nurse (RN) verified the MDS section for Restraints and Alarms did not include the wander/elopement alarm for R9. | 2020-09-01 |
| 3316 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 655 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure accurate completion of a 48 hour care plan for one (1) of one (1) resident reviewed for discharge planning. The Resident's 48 hour care plan failed to address the resident wanted to be discharged to the community. Resident identifier: #60. Facility census: 57. Findings included: a) Resident #60 Review of the medical record found the Resident was admitted to the facility on [DATE]. He was discharged to his home on 01/26/19. Review of the 48 hour baseline care plan noted the resident wished to remain in long term care. Record review found a progress note, completed by the social worker: 01/09/2019 01:14 PM This [AGE] year old white male resident is transferred to the care facility yesterday from (name of hospital). He is admitted for rehabilitation following a hospital stay. He is alert and able to verbalize needs and wants to staff. He is pleasant and interacts with staff without difficulty. He has good support from his brother and sister-in-law, with whom he lives. He reports that he often stays up until 12 or 1 am and chats with his brother and will get up around 9 or 10 am. He states his days consist of sitting around and watching TV and playing with the dog and cats. He says he usually only leaves the house for Medical appointments, and occasionally goes out to eat on those days with his brother, who transports him. He hopes to regain ability to walk and toilet himself and eventually return home with his brother. The social worker completed a discharge plan assessment on 01/09/19. The resident's short term goal was described as, To begin therapy and regain ability to walk and toilet self. The long term goal was, To return home with brother and community based services as indicated. At 4:06 PM on 04/09/19, the Registered Nurse care plan coordinator (RN) #74, acknowledged the resident's 48 hours care plan did not reflect the resident's desire to return home. In addition, the 48 hour care plan was never updated to reflect the resident's desire to return to his home. | 2020-09-01 |
| 3317 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 656 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement and/or develop resident care plans. For Resident #12 and Resident #56 the facility failed to implement their Diabetes Mellitus (DM). For Resident #9 the facility failed to develop a care plan in area of behaviors. Finally, for Resident #54 the facility failed to implement the residents care plan in regards to a smoking cessation program. This was trued for four (4) of 21 care plans reviewed. Resident identifiers: #12, #56, #9 and #54. Facility census: 57. Findings included: a) Resident #12 A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: --Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. --Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. Review of Resident #12's care plan found the following problem statement: Potential for hyper/[DIAGNOSES REDACTED] other complications Related to [DIAGNOSES REDACTED]. The goal associated with this problem statement read as follows: Will remain free of signs or symptoms or complications related to diabetes evidenced by labs and blood sugar checks will be in normal range through next review. The target date for this goal was 04/16/19. The was initiated on 01/18/19. The interventions associated with this problem and goal included: Administer medications as ordered and monitor for side effects and effectiveness. This goal was added on 10/24/18. An additional interview with the DON on 04/10/19 at 10:30 a.m. confirmed Resident #12's care plan was not implemented. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: --02/27/19 - 7:50 p.m. blood sugar was 278. --03/29/19 - 9:11 p.m. blood sugar was 235. --04/01/19 - 9:19 p.m. blood sugar was 236. --04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. Review of Resident #56's care plan found the following problem statement: Potential for hyper/[DIAGNOSES REDACTED] other complications Related to [DIAGNOSES REDACTED]. The goal associated with this problem statement read as follows: Will remain free of signs or symptoms or complications related to diabetes evidenced by labs and blood sugar checks will be in normal range through next review. The target date for this goal was 07/18/19. The was initiated on 04/02/19. The interventions associated with this problem and goal included: Administer medications as ordered and monitor for side effects and effectiveness. Receives [MEDICATION NAME] R sliding scale. This goal was added on 02/07/17. An additional interview with the DON on 04/10/19 at 10:30 a.m. confirmed Resident #56's care plan was not implemented. c) R9 During a medical record review on 04/08/19 for R9 revealed the care plan had not been developed to provide any structured programs or activities of interest to minimize his wandering behaviors of entering other residents room and trying to open closed doors. In a interview with the E74 registered nurse (RN) on 04/09/19 at 11:15 AM, verified the care plan had not been developed to provide any redirection interventions for R9's wandering behaviors. d) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking. | 2020-09-01 |
| 3318 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 657 | D | 0 | 1 | KGJN11 | Based on resident interview and staff interview, the facility failed to ensure Resident # 48 was in attendance and /or included in his care plan meeting. This true for one (1) of one (1) reviewed for care planning. Resident identifier: #48. Facility census: 57. Findings included: During an interview, on 04/08/19 at 12:05 PM, Resident #48 stated that he always attends his care planning meeting, but for whatever reason no one came to take him to his last meeting. He stated that he got up and ready, but they must have had it without him. He stated that the letter said it was schedule for 04/04/19. He received a letter requesting him to attend. During an interview on 04/08/19 at 12:17 PM, Registered Nurse (RN) #74 said, that they had his care plan meeting on 3/14/19 in his room. She further stated he did not attend the one held on 04/04/19. The RN stated she did not know he wanted to attend the one for last week. She stated that normally he does attend. She said it may have slipped though the cracks because they have a new Social Worker and she is not sure she knows how they do it yet. She also stated that they would reschedule one for next week for him. | 2020-09-01 |
| 3319 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 677 | E | 0 | 1 | KGJN11 | Based on observation, resident interview, staff interview, facility policy and record review, the facility failed to provide a resident with necessary services to maintain grooming and personal hygiene. This was true for two (2) of three (3) residents reviewed in the care area of Activities of Daily Living (ADL). Resdient identifiers: #33 and #5. Facility census 57. Findings included: a) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated that she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log verified Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, and she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN verified the resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey. b) Resident #5 During an observation of wound care on 04/10/19 at 2:08 PM, Licensed Practical Nurse (LPN) #55 and Nurse Aide (NA) #17 removed the adult brief on Resident #5 and revealed she had had a bowel movement. There was fecal matter on the front and back of this resident. Review of the facility policy titled, Perineal Care with revision date 2005 listed the following: The following equipment and supplies are necessary when performing this procedure: 1. Wash basin 2. Towels 3. Washcloths 4. Soap 5. Gloves --Place wash basin and supplies at bedside for easy access. --Fill the wash basin 1/2 full --For female residents wash perineal area from front to back --Separate the labia and wash area downward --Wash from inside to out including thighs --Do not reuse the same washcloth NA#17 left the room and returned with one wash cloth and one towel. She did not use a basin she wet the wash cloth in the sink and sprayed peri cleaner on the wash cloth. She smeared the fecal matter across the residents pubic area, using the same wash cloth she smeared more fecal matter across her buttock, enough to cover the sacrum area. She and the LPN replaced her brief and pulled her dress back down and was going to take her back to the dining area for activities. The LPN was interviewed about whether the peri-care was appropriately provided. LPN#55 stated that she would get the supplies and make sure she was cleaned properly. On 04/10/19 at 3:00 PM, DoN was informed of the observation and provide a competency for NA#17 that showed she did her yearly competency on 02/12/19. She also stated that she will re-educate this NA on peri care. | 2020-09-01 |
| 3320 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 684 | K | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resident #35 the facility failed to ensure that the physician had provided orders for medications prior to them being administered. Finally, for Resident #54 the facility failed to respond an implement a smoking cessation program when the resident had requested one be implemented. These were all random opportunities for discovery. Resident identifiers: #12, #56, #35, and #54. Facility Census: 57. Findings included: a) Resident #12 1. Sliding Scale Insulin A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. 2. Diabetic Protocol (Hypoglycemic Incident) A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found Resident #12's blood sugar was only 57. A review of the facility's Diabetic Protocol found the following, .If Glucose less than 60: If Resident is conscious, cooperative, and able to take fluids by mouth: -- Administer *(1) one full tube of glucose paste per package directions. Repeat glucose in 15 minutes. If glucose still less than 60, and resident remains stable as above repeat administration with another full tube of glucose paste (MONTH) give a total of 3 glucose pastes following same protocol before notifying physician. Recheck glucose in 15 minutes. If glucose greater than 60 with resident stable, notify physician on next facility round. Hold Scheduled insulin and oral hypoglycemic's until glucose greater than 200. Monitor glucose every 30 minutes time four (4), then every hour for two hours Further review of the medical record found no evidence the hypoglycemic protocol was ever implemented. An interview with the DON at 11:00 a.m. on 04/09/19 confirmed the hypoglycemic protocol was not implemented when the residents blood sugar was less than 60. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: -- 02/27/19 - 7:50 p.m. blood sugar was 278. -- 03/29/19 - 9:11 p.m. blood sugar was 235. -- 04/01/19 - 9:19 p.m. blood sugar was 236. -- 04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. c) Facility's Plan of Correction The facility's plan of correction read as follows: 4-9-19 Physician order [REDACTED].#56 and #12 and to monitor glucose checks BID for 14 days, if less than 250mg/dL then decrease to 3 times a week. All licensed nursing staff in the building beginning 4-9-19, will be educated regarding use of Diabetic Protocol, followed by education provided during shift change to all incoming licensed nursing personnel and will continue until all licensed personnel have been educated. Daily audit for four weeks, then a weekly audit four weeks, followed by a random audit to be reviewed in morning meeting and in facility Quality Assurance meetings on any resident receiving sliding scale insulins. d) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/25/19, the resident returned to the facility from an outpatient procedure with the urologist. The facility had orders to hold the resident's Aspirin (ASA) and Eliquis 7 days prior to the procedure. The medication was held as directed. When the resident returned to the facility, the physician wrote hand written orders for, (MONTH) resume ASA and Eliquis when urine output is clear. Record review found a nurses note dated 03/25/2019 at 5:11 PM. Resident returned from (name of hospital/name of physician) at approximately 4:45 p.m. via (name of ambulance) wheelchair van without incident. Returned with two scripts. Keflex 500 mg one capsule PO (my mouth) Q (every) 8 hrs (hours) x 5 days. [MEDICATION NAME] 10 mg one tab PO QHS. Return appt. (appointment) Monday, (MONTH) 27, 2019 at 10:30 a.m. (MONTH) resume all meds except for anticoagulant medication, may resume that after urine clears up. A second nurses note dated 03/26/19 at 12:55 PM, .Resident had only voided once since returning from (name of hospital) as of medication pass time this AM. Urine is now clear and can resume ASA and Eliquis tomorrow. Review of the medication administration record found the medication was resumed. On 04/10/19 at 9:20 AM, the Director of Nursing (DON) was asked if a nurse can prescribe a medication without calling the physician for orders? The DON said the nurse would have looked at the resident's urine before resuming the medication. The DON could not find any evidence the physician was contacted and told by the nurse the urine was clear so the physician could order the medications ASA and Eliquis to be resumed. The DON was unable to verify how the nurse determined the urine was clear. The Resident's minimum data set (MDS) with an Assessment Reference Date (ARD) of 03/11/19 noted the resident was frequently incontinent of urine. e) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, she was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking. | 2020-09-01 |
| 3321 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 697 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide appropriate pharmacological interventions in accordance with physician's orders [REDACTED]. Resident identifier: #27. Facility census: 57. Findings included: During initial resident screening on 04/08/19 at 12:49 PM, Resident #27 stated My tail bone hurts me when I am up in my wheelchair for a long time, and sometimes my neck hurts. I used to take Tylenol at home, and it helped. Not sure if I am getting it here. Resident has been deemed by the facilily's attending physician to have capacity to make her own decisions, and a Brief Interview for Mental Status (evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15(highest score possible) out of 15 indicating intact cognitive response. Review of Medication Administration Record [REDACTED]. Progress note dated 03/01/19 by Registered Nurse (RN) #38 documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . On 04/09/19 at 11:27 AM, review of med record revealed resident does not have any current pharmacological orders for pain. Resident's care plan was silent for pain managment interventions. On 04/09/19 at 4:45 PM Licensed Practical Nurse (LPN) #30 verified that the Resident (MONTH) #27 does not have an order for [REDACTED]. Review of medial record on 04/09/19 at 4:42 PM revealed progress note dated 03/01/19 entered by Registered Nurse (RN) #38 that documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . At 4:50 PM on 04/09/19 review of Observation Book for the facility's attending physician revealed an entry dated 03/01/19 written by RN #38 that stated the following (typed as written): (Resident #27) takes Tylenol for arthritis at home. C/O(complained of) neck pain. Also [MEDICATION NAME] home for [MEDICAL CONDITION]. Here she has 2 tabs = 6mg [MEDICATION NAME]. On 04/10/19 at 9:18 AM during an interview the facility's attending physician verified that the check mark in the doctor's response column within the observation book log for communication regarding the resident with an entry date of 03/01/19 was his check mark and that it indicated he acknowledged the nurses request for Tylenol and [MEDICATION NAME] and he authorized those medications to be given. The facility's attending physician stated, It was also verbally presented to me the resident took these medications at home and I authorized the mediations to be continued, and to use [MEDICATION NAME] in the place of the Ambien. I don't know why the Tylenol was never ordered or given for pain, it should have been. | 2020-09-01 |
| 3322 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 730 | E | 0 | 1 | KGJN11 | Based on record review and staff interview, the facility failed to provide evidence of 12 contact hours for 3 of 5 sampled nurse aides. The facility failed to perform performace reviews for 3 of 5 sampled record reviews. Staff identifiers: #73, #69 and #52. Facility census 57. Findings included: a) NA #73 was hired on 09/20/10. Her records did not contain contact hours for inservice training done for (YEAR). The record provided no performance appraisal. b) NA #69 was hired on 09/12/17. Her record contained no inservice contact hours for (YEAR). The record contained no performance appraisal. c) NA #52 was hired on 06/05/18. Her record did not contain contact hours for inservice training done for (YEAR). The record contained no performance appraisal. d) During an interview, on 04/10/19 at 9:30 am, the Director of nursing (DON) stated she was unable to provide the contact hours for NA #73, #69 and #52. The DON stated she had been in the role of staff educator since the previous educator had left several weeks prior to the survey. The administrator was unable to provide explanation of the lack of performance appraisals. | 2020-09-01 |
| 3323 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 732 | E | 0 | 1 | KGJN11 | Based on review of facility records assignment sheets, staff postings and timecards, the facility failed to provide accurate staff posting for 04/05/19 and 04/06/19. Facility census 57. Findings included: a) Review of staff posting for 04/05/19 for the 2:00 PM to 10:00 PM shift indicated 4 nurse aides worked. Review of time cards indicated 3 nurse aides worked the entire shift. During an interview, on 04/09/19 at 4:34 pm, the DON stated the staffing assignment sheets and time cards were accurate not the staff posting. b) Review of staff posting for 04/06/19 for the 6:00 AM to 2:00 PM indicated 3 nurse aides worked. Review of the time cards indicated 2 nurse aides left the building during the shift. The DON and administrator both confirmed with the timecards that one NA was in the building from 9:20 AM until 2:22 PM. Both the the DON and administrator were aware of the staffing issue on 04/06/19. | 2020-09-01 |
| 3324 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 755 | E | 0 | 1 | KGJN11 | Based on policy review record review and staff interview, the facility failed to conduct appropriate reconciliation of a controlled substance at shift change for two (2) of two (2) medication carts reviewed medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 57. Findings included: a) Long hall medication cart During observation of Long Hall medication cart on first floor on 04/09/19 at 1:35 pm, shift to shift narcotic key count record was reviewed and found to be non-compliant. Shift to shift narcotic key count was not completed and co-singed by both nurses (nurse coming on duty, nurse going off duty) for a total of thirteen (13) times for the time frame of 03/02/19 through 04/09/19. No records dating back any further than 03/02/19 were found for Long Hall medication cart. Licensed Practical Nurse (LPN) #30 verified the records were incomplete, and that is the way the facility verifies the narcotic count to be correct at the end of each shift and should be done each time a new nurse accepts keys to the mediation cart for use. During observation of Short Hall medication cart on first floor on 04/09/19 at 2:30 PM, shift to shift narcotic key count record was reviewed and found to be non-compliant. The shift to shift narcotic key count record log was not accurately completed and co-signed by both nurses (nurse going off duty, nurse coming on duty) for a total of seventeen (17) times since 01/09/19. Inaccurate shift to shift narcotic key count log was verified as inaccurate by Licensed Practical Nurse (LPN) #37, and LPN #37 stated that the shift to shift narcotic key count record should be completed at the end of every shift by the nurse responsible for that particular mediation cart. During an interview on 04/09/19 at 3:10 PM, Director of Nursing (DON) #14 verified the shift to shift key count record log used for reconciliation of narcotics at shift change were not completed in an accurate manner, and facility has no way of knowing if the proper reconciliation process for narcotics were performed at shift change. The DON also stated, I do not know where the sheets (shift to shift key count record) are for long hall med (mediation) cart dated any further back than what you have (March 2019), I cannot find them and no one else knows where they are either. Review of Controlled Substances policy revealed the following under shift change controlled drug count highlights: Nursing staff must count controlled mediations at the end of each shift. The nursing coming on duty and going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. | 2020-09-01 |