| 187 |
SIGNATURE HEALTHCARE OF BUCKHEAD |
115110 |
54 PEACHTREE PARK DRIVE N.E. |
ATLANTA |
GA |
30309 |
2019-07-10 |
700 |
J |
1 |
0 |
UF4211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, facility and hospital clinical record review, review of the facility policy titled Bed Safety, and review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, the facility failed to provide an environment free from the risk of entrapment within the side rail or between the side rail and air mattress for two residents (R) (#23 and #24) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). The facility had not provided a Removal Plan at the time of exit on 7/10/19 therefore the IJ is ongoing. Findings include: Review of the facility policy titled Bed Safety revised 1/2/19 revealed the interdisciplinary team shall assess the residents sleeping environment, with input from the resident and family. If side rails are used their use must be reevaluated quarterly and as needed (prn). If a bed rail is to be used it will be installed when the attempt to use an appropriate alternative has not been effective and did not meet the resident's needs. Review of Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued 3/10/06 revealed reassessment of bed safety programs may be appropriate when accessories such as mattress overlays are added. Powered air mattress replacements are easily compressed by the weight of a patient and may pose additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bed rail may increase and pose an additional risk of entrapment. When rail entrapment occurred the most commonly injured body parts were the head and neck and 143 out of 145 events resulted in fatalities. Use of bedrails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bedrail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of [REDACTED]. Monitoring of the bed, mattress and accessories should be ongoing. Review of the undated FDA document titled Recommendations for Health Care Providers about Bed Rails revealed the facility should inspect and regularly check the mattress and bedrails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body . Inspect, evaluate, maintain and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. 1. A review of the clinical record revealed R#23 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Quarterly and Annual Minimum Data Sets ((MDS) dated [DATE], 2/5/19 and 5/7/19 revealed R#23 had a Brief Interview for Mental Status Score of 00, indicating severe cognitive impairment. R#23 was also assessed to require extensive two person assist for bed mobility, was totally dependent for transfers and had impaired movement of both upper and lower extremities on both sides. A review of Physician's Orders for R#23 revealed an order dated 1/15/19 for quarter side rails bilateral/enabler. On 4/16/19 the Physician ordered to discontinue (dc) side rails, continue air mattress with bolsters. On 6/4/19 the Physician ordered may have bilateral half ( 1/2) side rails to define bed boundaries, per family request. There were no orders prior to 1/15/19 for side rails. Review of the Evaluation for Use of Side Rails dated 10/31/18 and 11/8/18 revealed side rails were being considered to allow resident increased bed mobility. No was checked indicating the side rails would not assist the resident with bed mobility, transfer, avoiding rolling out of bed, or provide a sense of security. Recommendation was that side rails were not indicated at this time. One-fourth partial rails and one-half partial rails were checked on the 11/8/18 assessment but not addressed on 10/31/18. Side rails precautions and alternatives to side rails was not checked as being discussed with the resident or family/resident representative. Review of the Evaluation for Use of Side Rails dated on 4/10/19 (five months from the previous assessment and nine days after the entrapment of R#23) continued to reveal that side rails were not assisting the resident, that side rails were not indicated, and documented no reason for the side rails. The evaluation dated 4/10/19 indicated bilateral bolsters were added to the overlay and precautions and alternatives to side rails had been discussed with the resident and family/representative. There were no documented alternatives. The size of the rails was not addressed. Review of the Evaluation for Use of Side Rails dated 4/16/19 revealed the family agreed to the use of bolsters for the air mattress and continued to include that alternatives had been discussed with the family. The Physician discontinued the side rails on this date. A Social Service Progress Note dated 4/17/19 at 8:29 p.m. revealed on 4/8/19 a care plan meeting had been conducted with R#23's son and the Social Service Director (SSD), Director of Nurses (DON), Unit Manager, Wound Care Nurse, and a Certified Nursing Assistant (CNA). The fall risk, interventions in place due to the fall risk, and the risk of the side rails were discussed with the son and he agreed to allow the rails to be removed. There were no previous Social Service progress notes in the clinical record that referred to informing R#23's family of risks of side rails. A review of the care plan for R#23 revealed on 11/4/15, Activity of Daily Living (ADL) was identified as a problem. Interventions for this problem included assist with all transfers, turn and reposition, shifting weight to enhance circulation, range of motion (ROM) provided during ADL care, and on 3/23/17 side rail(s) as an enabler. A fall care plan developed on 11/4/15 revealed R#23 was at risk for fall related injury. On 4/1/19, the fall care plan problem was updated with a fall on 4/1/19 related to poor bed mobility and cognitive deficits. Interventions for fall risk updated on 4/1/19 included side bolsters to mattress and landing mat. Additionally, on 4/1/19, keep side rails down had been crossed through and updated with removed, indicating there were no side rails, dated 4/9/19. There was no other mention of side rails in any other care plans. Review of Event Manager revealed an incident occurred on 4/1/19 for R#23 as follows: R#23 was observed on floor on buttocks with neck lodge (sic) between bed and railing. Vital signs were as follows: blood pressure 146/87, temperature 97.5, pulse 68 and oxygen saturation 96%. R#23 had no falls in the last 90 days. Fall mats were documented in place next to the bed and the bed was in low position. The attending Physician for R#23 was notified on 4/1/19 at 6:23 a.m. and the Responsible Party (RP) was notified on 4/1/19 at 6:40 a.m. R#23 was transported to the hospital. No time was provided for this transfer. A description of precipitating factors included the air mattress on bed was inflated high. Continued review of the Event Manager revealed a staff member, Certified Nursing Assistant (CNA) DD, documented that the air mattress sometimes inflates too high and moves the patient. The roommate of R#23 had notified LPN GG that R#23 was on the floor. LPN GG documented that there was no injury. A review of the hospital clinical record revealed R#23 arrived in the ED on 4/1/19 at 7:40 a.m. and was seen by the ED Physician at 8:03 a.m. R#23 was transported by Emergency Medical Services (EMS). The ED Physician's History revealed the patient was found on the ground that morning with her neck between the bed rails. The ED Physicians Physical examination revealed R#23 had a contusion on the left parietal region (bruise on the left side of the top of her head). The radiologist's interpretation of a Computerized [NAME]ography (CT) scan for R#23 revealed she had a left frontoparietal scalp hematoma, otherwise no acute intracranial abnormality. The ED Physician also ordered a cervical spine CT scan. The radiologist's interpretation revealed R#23 had a history of [REDACTED]. R#23 was stable for discharge at 9:23 a.m. A list of active rentals of air mattresses as of 6/27/19 was reviewed and R#23 had been provided with her current air mattress on 8/19/18. The manufacturers recommendations for the brand of air mattress that was indicated on the above list of active rentals for R#23 were requested on 6/26/19 at 1:35 p.m.; however, were not received until 7/1/19 at 2:09 p.m. and included the following: * When using side rails and/or assist devices, use a mattress thick enough and wide enough so that the gap between the top of the mattress and the bottom of the side rails and the gap between the side of the mattress and the side rails is small enough to prevent a patient from getting his or her head or neck between the mattress and the side rail. Failure to do so could result in serious patient injury or death. * Failure to use bed rails in raised position could lead to accidental falls. Air mattresses have soft edges that may collapse when patients roll to that edge. A review of air mattress audits by the former wound care nurse for R#23 revealed the following: On 8/20/18 the air mattress of R#23 was documented on the audit sheet. Her documented weight was 119.5 pounds (lbs.) with a question mark and the bed setting was not documented. On 9/25/18 the air mattress of R#23 was listed on the audit sheet with a weight of 116.8 and a mattress setting of 150 lbs. On 10/5/18, R#23's air mattress audit was documented with a weight of 113.3 lbs. and no mattress setting. On 10/3/18, 10/15/18, 10/22/18, and 10/29/18, there were no initials to indicate who performed the audit. R#23's weight was documented as 113.3 lbs. and her low air loss mattress was set at 150 lbs. On 11/6/18, 11/12/18, 11/19/18 and 11/22/18, there were no initials on the audit sheet to indicate who performed the audit. R#23's weight was documented as 115.8 lbs. and the air mattress setting documented was 150 lbs. On 1/14/19, 1/20/19, and 2/5/19, the documentation of the audits of the air mattress had no mattress setting. There were no other audits of air mattress settings for R#23. A review of Quality Performance/Peer Review, Facility Plan of Action/ Continuous Quality Improvement dated 4/1/19 revealed the facility documented on 4/4/19 R#23's incident. Side rails on beds with air mattresses were reviewed and removed if possible. Manufacturers guidelines for all models of air mattresses being used in the building will be obtained and placed at the Nurse's Station. Licensed Nurses and CNA's will be educated on the location of manufacturer guidelines for air mattress use. Licensed Nurse will be educated on checking air mattress setting every shift, checking setting upon notification of problem and checking setting as patients weight changes .Licensed Nurse will be educated . not to use side rails with air mattress unless approved by the Chief Executive Officer (CEO) after entrapment zone review. Licensed Nurses will be educated on side rails: use, assessment, consents, Physician (MD) orders, and care plans. This education was documented initiated on 4/12/19. CNA's, Housekeeping, and Maintenance will be educated to only allow settings to be adjusted by Licensed Nurse or Equipment technician, and to notify Nurse if setting is bumped or changed. This education was documented initiated on 4/10/19. Review of educational records related to side rail entrapment, eliminating side rails, side rail use update, and air overlay with bolsters and positioning in bed properly for R#23 and a town hall meeting on 4/23/19 revealed 57 of 204 staff were educated. This equals 27.94% of all staff educated on side rail safety from 4/1/19 through 5/15/19. Review of the Evaluation for Use of Side Rails dated 6/14/19 revealed side rails for R#23 were evaluated again and included that her son preferred R#23 to have side rails to define the bed edge. The size of the rails indicated upper half rails were to be used. Alternatives to side rails were documented as addressed with the resident and family, but no alternatives were documented. The side rails were evaluated again on 6/20/19 for R#23 and were considered to allow resident increased bed mobility as an enabler/safety. The side rails were to assist the resident to avoid rolling out of bed and provide a sense of security. Observations were conducted as follows: On 6/26/19 at 9:40 a.m., R#23 was up in chair in room. There were half side rails on both sides of the upper half of her bed. A foam pressure relief mattress was on the bed. On 6/26/19 at 2:30 p.m., R#23 was centered in bed on left side with two top half side rails raised. On 6/27/19 at 7:45 a.m., R#23 was turned to the left and was in the center of the bed with two top half side rails raised. On 7/2/19 at 10:35 a.m., R#23 was turned to the right and was in the center of the bed with two top half rails raised. During an interview on 6/26/19 at 7:50 a.m., the former DON revealed R#23 has a history of traumatic brain and cervical spine injury from a motor vehicle accident eleven years ago and has been in this facility since her discharge from the hospital. R#23 has very little movement and requires total care. On 4/1/19, R#23 somehow rolled out of her bed and became entrapped with her head and neck between the side rail and the mattress. R#23 was sent to the hospital and had no injury. The RP received education related to the corporate policy to not have side rails on the beds of residents with air mattresses and he allowed the facility to remove the side rails. Then on 5/28/19, R#23 rolled out of bed again and had no injury, but the son requested the side rails be returned to the bed. The former DON revealed he consented to the air mattress being removed and a pressure relief mattress was put on the bed. The former DON revealed the air mattress on R#23's bed, and the other air mattresses in the facility, had no settings for variable air pressure that were accessible from the outside of the control panel, and there was no bed in the facility that was set on intermittent air pressure. The former DON revealed there was no possibility the air mattress had been set to maximum inflation. During an interview on 6/26/19 at 9:32 a.m., CNA XX revealed she received education related to the proper positioning of residents on air mattresses and watching for gaps between resident's side rails and mattresses that they could become trapped in and injured. CNA XX confirmed the education also included not changing any settings on the control panel and to notify the nurse immediately of the settings were accidentally changed or the mattress seemed to be over inflated. CNA XX revealed she has worked with R#23 for years and she has always had half side rails except for a few weeks after she was caught in the side rails, and also that she has never seen R#23 move her body or extremities independently. During an interview on 6/26/19 at 9:35 a.m., CNA YY revealed she has worked with R#23 many times and she was aware R#23 slid from her bed and her head and neck were caught in her side rail. CNA YY revealed she did not know how this happened because R#23 does not move at all. CNA YY revealed she has never seen R#23 use her side rails for any bed mobility. CNA YY revealed she did not remember attending education related to side rails and the danger of entrapment, and the increased risk of entrapment with air mattresses. CNA YY revealed she was aware that she should always observe for gaps that any resident could become entrapped in between the mattress and side rails, to not touch the control panel settings and to observe for air mattress over inflation and report to the nurse immediately if an air mattress seemed to be malfunctioning. CNA YY revealed R#23 has always had two top half side rails except for a few weeks after she fell the first time. Interview with the new Wound Care Nurse, LPN BB on 6/26/19 at 10:42 a.m. revealed she has been employed by the facility for three weeks and there were no user manuals or factory recommendations attached to the mattress, control panel, or in her office. The Wound Care Nurse revealed she had received education in orientation related to the risks of side rail entrapment and the risks of using air mattresses. Interview on 6/27/19 at 4:55 p.m. with the former DON revealed after reviewing the current and overflow clinical records for R#23, there was no consent for side rails or any indication the RP for R#23 had been informed that the side rails posed a risk for entrapment and that the addition of an air mattress increased the risk for entrapment. The former DON revealed that R#23 had probably had side rails for the [AGE] years she had been a resident in this facility. The former DON acknowledged that there were no side rail assessments found for R#23 prior to (MONTH) (YEAR), and that there is no documentation related to the alternatives to side rails that were attempted or discussed with the RP. The former DON revealed the resident representative had requested side rails after R#23 fell out of bed on 5/28/19. The former DON revealed she expected the Wound Care Nurses to explain the increased risk of using side rails with an air mattress to the resident/resident representative, and to monitor the settings on the air mattress control panels weekly. She revealed she had not reviewed the monitoring of the settings but was aware the former Wound Care Nurse kept them in her office. The former DON revealed she had not in-serviced the new Wound Care Nurse, here for three weeks, related to the weekly monitoring of the air mattress control panel settings. During a telephone interview on 6/27/19 at 5:39 p.m., the former Wound Care Nurse, LPN AAA revealed she remembers R#23 and remembers discussing the air mattress with the RP when it was applied to the bed last summer. LPN AAA revealed she had not provided any information to the resident/resident representative related to the increased risk of entrapment in side rails when used in conjunction with an air mattress. She did not consider that R#23 would have any increased risk because she had contractures of all four extremities and she could not move. LPN AAA revealed she monitored air mattress settings every Monday on every resident with an air mattress and filled out check lists that are located in the Wound Care office. LPN AA revealed she was Wound Care Nurse here for three and a half years and had never seen R#23 move and she had always had bilateral top half rails. She revealed she had never found any of the air mattress settings changed. She had never been told that R#23's air mattress could have been over inflated, and she had not received any education related to the increased risk of entrapment when air mattresses are used for residents with side rails before or after R#23 had been entrapped in her side rail. An interview was conducted on 6/28/19 at 7:16 a.m. with CNA DD. CNA DD was assigned to the care of R#23 on the morning of 4/1/19. CNA DD revealed the roommate of R#23 had called for help when R#23 was found on the floor with her head and neck entrapped in her side rail. LPN GG went to the room first and called for help. The resident was in a praying position on the floor with her head between the air mattress and the side rail which was up. CNA DD stated R#23 could not get up and the air mattress was inflated a lot. LPN GG adjusted the setting to what it should be. CNA DD revealed the resident was last seen by LPN GG at approximately 6:00 a.m. when she administered medications and the roommate called for help between 6:30 a.m. and 6:45 a.m. During an interview on 7/2/19 at 9:00 a.m., LPN BBB revealed she has worked with R#23 intermittently for nine years and she does not move on her own and she has always had two top half rails. LPN BBB revealed she was on duty when R#23 returned from the hospital after entrapment in her side rail and had not noted any bruising or swelling on her head. She revealed she had attended education a few days after the incident related to checking the settings on the air mattress control panel every shift or more often and checking for gaps between the side rails and the mattress and bed frame. An interview with the Staff Development Coordinator (SDC) on 7/2/19 at 9:50 a.m. revealed she had not included information related to the risks of side rails and air mattresses in CNA orientation prior to 4/1/19. The SDC revealed most of the CNA orientation is clinical and the orienting CNA's are provided with mentors and she did not know if any of the mentors mentioned side rail or air mattress risks. The SDC revealed since R#23 was entrapped she has started including information related to risks of side rails and air mattresses in the licensed nurse's orientation and does include their role in monitoring and adjusting settings on the air mattresses as well as monitoring the side rails for gaps and secure placement. An interview was conducted with the Customer Service Representative for the air mattress supplier on 7/3/19 at 11:33 a.m. The Representative revealed he does not recommend any specific setting for air mattresses and leaves this up to the facility and they should adjust according to the resident's comfort and body shape. The Representative revealed the weight settings are just a guide and he has seen them set as much as fifty pounds over what the resident weighs with no issues with the resident's safety. The Representative revealed the weight settings, maximum inflation and alternating pressure are all accessed from the control panel and can be easily changed. The Representative revealed there was always a chance of the resident rolling off the air mattress with the firmer settings and the resident should ideally sink into the mattress about four inches. Further interview with the former DON on 7/2/19 at 3:30 p.m. revealed she expected the Unit Managers, Charge Managers and the Interdisciplinary Team (IDT) to review all new orders and if the order is not appropriate such as ordering quarter rails as an enabler for R#23, this should be brought to the attention of the Physician and corrected. The former DON acknowledged that there are no quarter rails in the facility, only half rails and that R#23 is not capable of using side rails as an enabler. An interview was conducted on 7/2/19 at 4:20 p.m. with the third floor Unit Manager LPN FF. LPN FF was unable to locate any manufacturers guidelines or operators' manuals for the air mattresses for the residents on the third floor. An interview on 7/3/19 at 9:00 a.m. with the Therapy Manager revealed the therapy department has no part in side rail assessments. The Therapy Manager revealed she is very familiar with R#23 and is aware that R#23 does not have the capability to move due to cervical spine and traumatic brain injuries eleven years ago. The Therapy Manager stated she does not know how it would be possible for R#23 to independently move enough to fall off her bed twice. During an interview on 7/3/19 at 1:59 p.m., the Interim DON reviewed the air mattress setting audits conducted by the former Wound Care Nurse for R#23 and confirmed there were many blanks where the weight setting should be filled in, and there were many dates when the weekly monitoring was not completed. When monitoring was completed it did not always include R#23. The Interim DON revealed that education related to air mattresses and side rail risks, documentation and management that was initiated on 4/5/19 was still ongoing. The Interim DON revealed during her review of the audits of documentation she had found many residents without orders, with incomplete and incorrect assessments, and without informed consents for side rails. The Interim DON revealed that she is not sure all the documentation concerns have been corrected. During a telephone interview on 7/5/19 at 12:09 p.m., LPN GG confirmed she was on duty on 4/1/19 at 6:30 a.m. and had been passing medications on the fourth floor. LPN GG revealed she had given a medication in the room of R#23 at approximately 6:15 a.m. and then continued administering medications to other residents on the same hall when approximately 15 minutes later, R#23's roommate came out of the room and said loudly that R#23 was on the floor. LPN GG revealed she immediately went into the room and found R#23 sitting on her bottom on the landing mat beside her bed with her body facing the door and her head caught between the side rail and the mattress with her face turned to face the head of the bed. Her chin was resting on the bottom horizontal rail of the side rail and the bed was in the lowest position. R#23 was not making a sound, her eyes were open, and she was breathing without effort. LPN GG stated she shouted for CNA DD who came right away. They were able to slide the mattress over, put down the rail and get R#23 back into bed. LPN GG revealed the air mattress had felt tight like it was too full. LPN GG checked the settings on the air mattress control panel and the settings were the same as always. Maximum inflation and alternating pressure had not been activated. LPN GG revealed she remembered the weight setting was also where it always was whenever she checked it, on 120 lbs. She had not touched the settings but had reported she and CNA DD had both thought the mattress was over inflated and may have malfunctioned. She had worked with R#23 intermittently for over a year and had never seen R#23 move and could not think of how she could fall. LPN GG revealed she had performed a head to toe assessment and checked vital signs and there was no indication R#23 was injured. An interview with the Medical Director on 7/10/19 at 9:07 a.m. revealed she remembers discussing side rails at Quality Assurance meetings and agreed with the recommendations the committee made to reduce the use of side rails. The Medical Director was not able to remember discussing R#23 being entrapped in her side rail on 4/1/19. The Medical Director revealed she is involved in care planning for all aspects of resident care and expects care plans to reflect any risk to the resident's wellbeing, with side rails as a risk, and the additional risk of an air mattress. These risks should be considered problems for the care plans and require interventions for the resident's safety. The Medical Director confirmed this should be explained to all residents and families that are consenting to side rails. An interview on 7/10/19 at 10:10 a.m. with the Administrator revealed her first day in facility was 6/4/19 and she was not given any information that a resident had been entrapped in side rails until the surveyors arrived. Meetings take place daily related to preventing falls, assessing individual needs, care planning and accuracy of orders. The Administrator revealed she attends at least three clinical meetings a week. The Unit Managers are expected to provide accurate updates and provide the Interdisciplinary team with new problems and risks for any resident whose care plan does not represent accurate information related to risks such as side rails and air mattresses. 2. Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan dated 12/22/18 noted R#24 was at risk for falls related to weakness. Interventions included side rails bilateral (enabler). Review of the Evaluation for Use of Side Rails for R#24 dated 1/20/19 revealed the use of side rails were being considered for R#24 to allow resident increased bed mobility. However, the same document indicated the resident's mobility is very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. In addition, the Quarterly MDS assessment dated [DATE] Section G0110A Bed mobility revealed that R#24 requires total assistance to move in bed. Section C0500 Brief Interview for Mental Status is coded 00 which indicates R#24 was severely cognitively impaired and unable to be interviewed. Review of a document dated 1/30/19 titled Daily Skilled Nursing Note revealed R#24 is alert and responsive, non-verbal. Requires total dependence on staff for all ADL's and transfers. Review of the Progress Note for R#24 dated 2/3/19 at 11:19 p.m. revealed residents right leg caught in bed rail. No bruising noted. Right leg and ankle [MEDICAL CONDITION]. No obvious signs of injury. Review of the Physician's telephone order dated 2/4/19 revealed Right Knee x-ray 2 views and Right ankle x-ray 2 views, indication: pain and swelling. Review of document titled SHC NP (Nurse Practitioner) Medical Partners dated 2/4/19 revealed, Chief Complaint/History of Present Illness, lower leg pain, Patient noted with right leg caught in side rail of bed, onset of symptom -1 day ago. Mechanism of injury-direct trauma. Severity -mild, Pertinent Findings- swelling, denies bruising, denies decreased range of motion, denies pain with movement and denies warmth. Review of page 3 of 3 included the NP's Plan; right leg pain, X-ray right knee and ankle continue to monitor for changes/worsening and symptoms, Nursing to continue assistance with ADL's and care, Tylenol as needed for pain, Elevate extremity and rest. Will |
2020-09-01 |