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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10695 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 280 | E | 1 | 1 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to revise the care plans for six (6) of forty-five (45) Stage II sample residents. These residents' needs and requirements for care changed; however, the care plans were not revised to reflect the changes. When the level of staff assistance with meals changed for four (4) residents, no revisions were made to the care plans to address the increased need. There was also no revision for falls for two (2) residents. Resident identifiers: #71, #128, #1, #101, #206, and #214. Facility census: 105. Findings include: a) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her uneaten meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously, beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m., until 8:30 a.m. when the tray was removed from the resident's room. Review of the resident's care plan, dated 07/25/11, revealed the resident required tray set up and "assistance as needed". The Kardex, which is the plan used by nursing assistants, did not correlate with this. The Kardex noted the resident was "independent" with eating meals. Observation revealed the resident required more assistance than was noted in the care plan and Kardex. The care plan had not been revised to reflect the resident's current needs at mealtime. -- b) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:30 a.m. when the tray was removed from the resident's room. Review of the resident's unscheduled MDS, dated [DATE], noted the resident was independent in eating. This was also noted on the Kardex used by the nursing assistants. Review of the resident's current care plan, dated 05/11/11, found the resident was able to "feed self after tray setup". The care plan had not been revised to reflect the resident's current needs at mealtime. -- c) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not offered assistance prior to removal of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. Review of the resident's care plan revealed no plan for assistance at meals. Additionally, the Kardex indicated the residents was independent in eating. The care plan had not been revised to reflect the resident's current needs at mealtime. -- d) Resident #101 On 08/02/11 at 8:00, this resident was observed asleep with her uneaten breakfast in front of her. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not awakened or offered assistance prior to removal of her meal. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m. until 8:35 a.m., when the tray was removed from the resident's room. The resident's care plan plan was reviewed on 08/02/11. The care plan, dated 03/18/11, had an intervention to "(a)ssist the resident with feeding PRN (as needed)." At the time of the survey, the resident required more extensive assistance with eating than was indicated in the care plan. -- e) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled "Determination of Capacity / Incapacity / Designated Surrogate", which was not signed or dated. The person completing this form checked Item C "_______ demonstrates INCAPACITY to make medical decisions" and designated the resident's daughter to serve as health care surrogate. Upon the resident's admission to the facility, no physician's determination of capacity was made. (A form titled "Physician's Determination of Capacity" was found in Resident #206's medical record; it was signed by the physician and dated 07/06/11, but the form was otherwise blank - with no indication was to whether the resident did or did not possess the capacity to understand and make her own health care decisions.) On the day of her admission (06/20/11), a "Resident Fall Evaluation" form was completed. The assessor recorded "Y" for "yes" in response to the following questions: - "fell in Last 30 Days?" - "Has there been a change in mobility?" - "Has there been a change in gait?" - "Does resident need assistance with bed mobility, transfer or ambulation?" - "Has resident had changes in their medication?" - "Is resident on any new medications?" - "Does resident wear glasses?" - "Can the resident communicate their needs?" - "Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?" - Review of the resident's physician orders [REDACTED]. - 06/20/11 - "[MEDICATION NAME] 0.5mg tab By mouth (oral) - PRN PRN: Give Q 8 hours prn - [MEDICAL CONDITION]" - 06/21/11 - "[MEDICATION NAME] ([MEDICATION NAME]) 1 MG Tablet By mouth (Oral) - Every four hours Everyday: Hold [MEDICATION NAME] if drowsy - Anxiety" - Episodic care plans, dated 06/21/11, included the following problems, goals, and approaches (quoted as written): - Problem - "(Arrow pointing down) ADL (activities of daily living), weakness, (arrow pointing down) activity tolerance, (arrow pointing down) balance, (arrow pointing down) mobility." Goal - "Max I (maximum independence) /c (with) ADL for safe D/C (discharge) to appropriate level of care." Approaches - "See HCFA 700 for POC (plan of care)." (This care plan was written by the occupational therapist.) - Problem - "(Arrow pointing down) cognitive skills." Goals - "(Arrow pointing up) cognitive skills." Approaches - "See HCFA 700 for POC." (This care plan was written by the speech-language pathologist.) - Problem - "(Arrow pointing down) bed mob (mobility), (arrow pointing down) transfer, (arrow pointing down) amb (ambulation)." Goal - "Safe / I to return to Home." Approaches - "See HCFA 700." (This care plan was written by the physical therapist.) No care plan was developed upon admission to address the resident's risk for falls, which would have been appropriate given the [MEDICATION NAME] risk factors for falling that had been identified on the "Resident Fall Evaluation" form completed on the day of her admission. -- 2. According to an incident / accident report dated 06/22/11 at 2:15 p.m. (quoted as written): "Resident was in bathroom in her room doing an unassisted ambulation. Resident went to sit on toilet & fell . Resident hit (L) (left) forehead on floor has hematoma there (symbol for 'no') C/O (complaint of) pain. (Symbol for 'no') further distress noted." On Page 2 of the incident report, the results of the facility's investigation into this fall were as follows (quoted as written): "(Symbol for 'no') further injuries. Bed locked in lowest position. Call light in reach." A "Fall Investigation Worksheet" form, dated 06/22/11, identified the resident fell from a standing position, she was wearing socks but no shoes at the time of the fall, she was receiving narcotics and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. A "Resident Fall Evaluation" form was completed on 06/22/11, on which the assessor recorded "Y" for "yes" in response to the following questions: - "fell in Last 30 Days?" - "Has there been a change in mobility?" - "Has there been a change in gait?" - "Does resident need assistance with bed mobility, transfer or ambulation?" - "Is the resident confused?" - "Has there been a change in mental status?" - "Does resident wear glasses?" - "Can the resident communicate their needs?" (The assessor responded "N" for "no" to the question "Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?", although the resident continued to receive medications that affected blood pressure and the episodic care plan discussed below identified the need to monitor the resident's orthostatic blood pressure every shift.) On 06/22/11, an episodic care plan was developed as follows (quoted as written): - Problem - "Fall /c (with) hematoma to (L) (left) forehead." Goal - "(Symbol for 'no') further falls." Approaches - "(1) Bed locked in lowest position. (2) Call bell in reach. (3) Room clutter free. (4) Notify MD of (symbol for 'changes')." A second problem statement also dated 06/22/11 stated: - Problem - "Fall /c hematoma." Goal - "(Symbol for 'no') further falls." Approaches - "(5) Orthostatic B/P (blood pressure) QS (every shift). (6) [MEDICATION NAME] 0.5 mg q (every) 4 hours. Hold if drowsy. (7) [MEDICATION NAME] 0.5 mg q 8 hours PRN (as needed)." This episodic care plan did not take into account the information recorded on the "Resident Fall Evaluation" form, which noted the resident had exhibited a change in mental status and was now confused - two (2) [MEDICATION NAME] fall risk factors that had not been identified on the "Resident Fall Evaluation" form completed on 06/20/11. - Review of the resident's physician orders [REDACTED]. - 06/26/11 - "Apply bed alarm to bed for residents safety and check for placement every shift R/T (related to) H/O (history of) Falls. - Every Shift Everyday" - 06/26/11 - "Apply chair alarm and check placement every shift for resident's safety R/T H/O Falls - Every Shift Everyday" - 06/26/11 - "Apply safety mats at bedside for resident's safety while in bed and check placement every shift, while in bed R/T H/O Falls - Every Shift Everyday" -- 3. According to an incident / accident report dated 07/01/11 at 4:15 a.m. (quoted as written): "Resident attempted to sit in a chair, missed the chair, and slid to floor landing on buttocks. Moves all extremities /s (without) difficulty." This fall occurred at the nurses' station. A "Fall Investigation Worksheet" form, dated 07/01/11, identified the resident fell from a standing position when attempting to sit, she had an unsteady gait, she was wearing socks and shoes at the time of the fall, she was receiving antipsychotics, antianxiety medications, narcotics, and antihypertensives, and she was confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. - On 07/01/11, the comprehensive care plan was updated with the following problem, goal, and interventions (quoted as typed): - Problem - "Potential for further decline in cognition related to [DIAGNOSES REDACTED]." Goal - "Respond to questions/ statement with appropriate verbalization and will know where she is and current month and year when ask at least 5 out of 7 days per week thru next review." (Target date: 09/20/11) Interventions - "Give one simple direction at a time and repeat it as necessary. Encourage participation in self-care within individual abilities. Encourage small group activities. Establish daily routine with resident. Explain each activity/ care procedure prior to beginning it. Provide reality orientation. Observe and report changes in cognitive status. Keep questions simple. Ensure access to clock/ calendar." Additionally on 07/01/11, an episodic care plan was developed as follows (quoted as written): - Problem - "Fall." Goal - "(Symbol for 'no') further falls through review." (No review date was provided that would make this goal measurable.) Approaches - "(1) Necessary items within reach at all times. (2) Call light within reach. (3) Bed alarm / chair alarm. (4) Floor matts. (5) Encourage resident to ask for assistance /c (with) all xfers (transfers)." A form titled "Multidisciplinary Screening Form", dated 07/01/11 and completed by the physical therapist, found the following (quoted as written): "4:15 am - 7/1/11 - patient was sitting in a chair missed the chair and fell pt (patient) is on caseload." -- 4. A nursing note, dated 07/02/11 (with no time), stated (quoted as written): "Resident keep getting up and turning off her alarms. Will not listen to reason. She keeps getting up and staggering around. Reported to charge nurse." The next consecutive note (which was no in chronologic order when viewed with the rest of the nursing notes on other pages), was dated "7/9/10/11 7p-7a" and stated (quoted as written): "Resident turns her alarms off and walks around the nurses desk and her room. She refuses help and says she can do it herself." Additional entries in the nursing notes periodically noted Resident #206 was alert and oriented to person and place only, with episodes of confusion noted at times. On 07/06/11, the order for placement of floor mats beside the resident's bed was discontinued. -- 5. According to an incident / accident report dated 07/11/11 at 5:17 p.m. (quoted as written): "Resident fell in dinning room. Chair alarm didn't alarm until resident was in floor. Resident fell on left side. C/O (complained of) left shoulder pain. 3cm S/T (skin tear) to left elbow." A "Fall Investigation Worksheet" form, dated 07/11/11, identified the resident fell while engaging in unassisted ambulation from her wheelchair, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was alert. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", the person who completed this section (which was not signed or dated) wrote: "Advise resident not to ambulate without help. Apply new alarm pad." A nursing note, dated 07/11/11 at 1815 (6:15 p.m.), stated (quoted as written): "Resident fell in dining room chair alarm was on but did not activate alarm til resident was on floor. She said she hit her head. C/O left shoulder pain 3 cm skin tar at elbow. ... Called Dr. (name) wants sent out for X-Rays ..." A nursing note, dated 07/13/11 (with no time noted), stated (quoted as written): "late entry for 7/11/11 Resident is noncompliant of chair alarm. Explain to resident the importance of chair alarm & resident is still non-compliant." A nursing note, dated 07/11/11 at 2200 (10:00 p.m.), stated (quoted as written): "Resident back from hospital ... Res dx of (illegible) fx (fracture) of the clavicle. N.O. (new order) for [MEDICATION NAME] q 6 hours PRN for pain #15. Report from hosp stated resident to be careful of falls. ..." An episodic care plan was developed on 07/11/11 with the following (quoted as written): - Problem - "Fall /c injury to (illegible)." Goal - "(1) Resident will have (symbol for 'no') more falls (illegible)." Approach - "(1) Resident to be instructed on call light to call for assist /c transfer to bathroom & other needs assist x 1 /c ambulation QS." (This intervention identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's [MEDICAL CONDITION] and decline in cognition associated with the progression of the resident's [MEDICAL CONDITION].) A form titled "Multidisciplinary Screening Form", dated 07/12/11 and completed by the physical therapist, found the following (quoted as written): "7/11/11 - pt (patient) fell - on caseload for balance, safety awareness due to poor judgment Working /c Daughter re: (regarding) inability to direct patient to safe behavior spoke /c them re: DC (discharge) placement since pt won't follow Directions." -- 6. According to an incident / accident report dated 07/12/11 at 6:10 p.m. (quoted as written): "CNA (certified nurse aide) escorted resident to room after dinner. CNA had to go help get other residents fr (from) dining room. Pt (patient) was in chair when CNA left room. Another CNA was passing by in hallway and heard a thump and quickly ran to room for help. The alarm was not going off when room was entered. Pt is known to turn off chair alarm. Found pt laying on (L) (left) side laceration above (L) eye brow & skin tear on top of (L) wrist & complaining of (L) hip pain. Resident sent out immediately." This fall occurred in the resident's room. A "Fall Investigation Worksheet" form, dated 07/12/11, identified the resident fell from a stationary chair and that she was trying to transfer herself from chair to bathroom, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. The next consecutive nursing note following the resident's return from the hospital on [DATE], dated 07/12/11 at 1815 (6:15 p.m.), stated (quoted as written): "Resident fell in room. Laceration on (L) side of head. C/O (L) hip pain. Called Dr. (name) ... Dr. (name) said send to ER (emergency room ) ... also has aprox 3cm skin tear to top of (L) wrist." The next consecutive nursing note, dated 07/12/11 at 2315 (11:15 p.m.), stated (quoted as written): "Resident back from (hospital) ... Resident alert. Steri-strip noted to laceration (L) side of head. (Symbol for 'no') new orders sent per Hosp. Dr. (name) called. N.O. for resident to be instructed to use call light for assist for transfer for bathroom or other needs et (and) assist of 1 for ambulation as (illegible) (checkmark) compliance QS (every shift). ..." An episodic care plan was developed on 07/12/11 with the following (quoted as written): - Problem - "Pt had fall in room." Goal - "Pt will free of falls for next evaluation." Approach - "(1) Encourage pt to use call light. (2) Encourage pt to shout out for help. (3) Call light within reach." (Again, these interventions identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's [MEDICAL CONDITION] and decline in cognition associated with the progression of the resident's [MEDICAL CONDITION].) A form titled "Multidisciplinary Screening Form", dated 07/13/11 and completed by the physical therapist, found the following (quoted as written): "7/12/11 - pt (patient) fell - on caseload for safety see previous fall screen 7/11/11 same issues as previously noted." -- 7. According to an incident / accident report dated 07/18/11 at 12:30 p.m. (quoted as written): "Resident stood up out of w/c (wheelchair). I redirected resident. While resident was sitting back down, w/c rolled back resident fell to floor on left side. Resident has c/o (complained of) pain (L) leg. N/O (new order) for x-rays obtain. Neuro's started." This fall occurred in the dining room. A "Fall Investigation Worksheet" form, dated 07/18/11, identified the resident fell from a wheelchair while attempting unassisted ambulation, she had a malignant neoplasm of the brain and spinal cord, she was wearing socks and shoes at the time of the fall, she was receiving antianxiety medications, narcotics, and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. A form titled "Multidisciplinary Screening Form", dated 07/19/11 and completed by the physical therapist, found the following (quoted as written): "7/18/11 - pt fell in DR (dining room) trying to get up out of chair. Antiroll (illegible) orders for wc (wheelchair) Patient on caseload being DC's (discharged ) - today Daughter aware working /c family for safety awareness." After the resident sustained [REDACTED]. They continued to rely on the intervention of reminding the resident to use her call light for assistance. No new interventions by nursing or therapy staff were added between the falls on 07/11/11, 07/12/11, and 07/18/11. -- 8. Review of the facility's Fall Management Program (adopted January 2008; revised December 2010) found the following expectations in Section 1 (Fall Prevention) (quoted as typed): "... A licensed nurse performs a head-to-toe evaluation of each new admission. When evaluating a resident who may be at risk for falling, the licensed nurse should consider the medical history, [DIAGNOSES REDACTED]. .. "... After the head-to-toe assessment, the licensed nurse completes a Fall Evaluation on every new admission. This evaluation identifies both the [MEDICATION NAME] and extrinsic risk factors that apply to the particular resident. "... Once the assessment and evaluation are completed and risk factors have been identified, the licensed nurse selects appropriate interventions. The Fall Evaluation Intervention tool is utilized to provide a standardized, quick, easy to use crosswalk that relates risk factors to suggested interventions. These practical intervention options can help the licensed nurse with the next task - developing a comprehensive individualized Care Plan. ... "... Each week, the interdisciplinary team teams residents who are new admissions and residents who have fallen in the past 90 days during the C.A.R.E. meeting. The knowledge and expertise that is shared at these meetings enhances the quality of care provided to residents. During the C.A.R.E. meeting, care strategies are evaluated and the care plan is adjusted, as necessary. ..." - The following expectations were found in Section 2 (Fall Management) (quoted as typed): "... A specific procedure is followed to report and investigate falls. This ensures that the resident receives appropriate care after a fall, that an investigation is begun, and that the resident's care plan is adjusted, as needed. ... "... After the resident has been cared for (when a resident falls), the licensed nurse: "1. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. Note: Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress Notes during each shift for the next 24 hours, and daily for the next 48 hours, noting any changes in condition - a total of 72 hours) "2. Completes a Fall Evaluation to determine if there have been any changes in resident condition and to identify interventions that may help in preventing future falls "3. Completes an incident and accident report ... including a fall investigation "4. Updates the Care Plan with the identified interventions "5. Updates the Nursing Assistant Care Card with any new procedures "6. Completes the 24-Hour Report, to alert following shifts to the fall, as well as Care Plan updates "7. Residents are followed via the 24 Hour Report x 72 hours ..." -- 9. When interviewed on the afternoon of 08/04/11, Employee #9 (the minimum data set manager) reported the facility wanted to initiate a program that would date the alarms and alert staff as to when these alarms / batteries needed to be changed. An interview with the registered nurse (RN) consultant (Employee #28A), on 08/04/11, revealed the facility had not conducted the C.A.R.E. meetings as stated in the Fall Management Program provided by the facility. Employee #28A said the facility had not conducted these meetings due to not having a director of nursing. However, the facility utilized an interim director of nursing (DON - Employee #27A) during the time period these falls occurred. -- 10. On 08/04/11 at approximately 3:00 p.m., Employee #1A (the therapy program manager) said the resident experienced a lot of agitation while at the facility. Her functioning abilities fluctuated. She said this made the resident's abilities difficult to judge. She said the facility did not try a Rock-N-Go chair with this resident, but this may have been beneficial to her. On 08/04/11 at approximately 3:15 p.m., Employee #9 said the resident often tried to get up from her chair when her family would leave the facility. The facility did not incorporate into the care plan and/or develop approaches to promote resident safety based on this information. -- f) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED].". Resident #214's interim care plan, which was initiated upon her admission on 07/19/11, did not address the resident's risk for falls, even though staff was aware that the resident had sustained one (1) or more falls prior to her admission. - According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or whether she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound VAC to measure and apply a new dressing. The wound VAC dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. - On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her Medication Administration Record [REDACTED].) Review of the "Resident Fall Evaluation" completed on 07/23/11 revealed the assessor wrote "N" for "no" in response to the following questions: - "Has resident had changes in their medication?" - "Is resident on any new medications?" - "Was resident experiencing pain prior to the fall?" An episodic care plan, dated 07/23/11, contained the following problem, goal, and approaches (quoted as written): Problem - "Fall r/t (related to) poor safety awareness." Goal - "No further falls." Approaches - "(1) Call bell in reach. (2) Visualize resident frequently. (3) Safety mats to bedside when in bed. (3) Pressure alarm to bed to alert staff to unassisted transfers." On 07/24/11, nursing notes stated: "S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place." There was no documentation to reflect the resident had been exhibiting any behaviors at that time. -- 2. Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. - On 07/27/11, the resident's medical record was reviewed for documentation of the factors surrounding this resident's falls. There was no contemporaneous entry in the nursing notes to correspond with the fall on 07/26/11, and there was no evidence to reflect staff conducted a physical assessment of the resident and no evidence to reflect staff conducted an investigation to identify possible [MEDICATION NAME] and/or extrinsic factors that may have contributed to this fall. A nursing note, dated "07/24/11", stated Resident #214 had a fall on 07/26/11. This was brought to the attention of Employee #28A, who stated this note was probably dated incorrectly, because it was written after a note dated 07/25/11. She said this note must have been intended for 07/26/11, as the next consecutive note, dated 07/27/11, stated the resident had no further falls. Employee #28A verified there was no note in the medical record to describe the details of the fall that had occurred on 07/26/11. - The facility's incident / accident reports were reviewed, and no report was found for Resident #214's fall on 07/26/11. Additionally, "Resident Fall Evaluation" and "Fall Investigation Worksheet" forms were not completed following this fall on 07/26/11. - Subsequent review of the resident's care plan found it was not reviewed / revised after the fall on 07/26/11 as required by the facility's Fall Management Plan, to include new or different interventions to prevent future falls from occurring. . | 2014-12-01 |