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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11480 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 279 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: "Refer to the physical restraint / enabler assessment." 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, "Refer to the physical restraint / enabler assessment." The goal associated with this problem was "(Resident) will be free of negative effects with the use of an enabler." This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which, when reviewed, did not refer to the lap buddy in any way); refer to the falls assessment prevention and management plan of care (which did not include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy): prevention and management plan of care; maintain resident bowel and bladder routine; educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was incomplete). The care plan for this resident's lap buddy use did not specify the problem necessitating the application of the device. Additionally, record review revealed the resident became agitated and had sustained injuries when the device was applied, and this response was not addressed in the resident's care plan. b) Resident #10 Review of the interdisciplinary care plan for Resident #10, found a fifty (50) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan stated, "Recent or chronic history of incontinence. Contributing factors included laxative use PRN and cognitive / perceptual impairment, loss of sphincter control, and decreased physical activity." One (1) goal for problem statement was: "Will ingest adequate fluids evidenced by resident's skin turgor." Other goals were: "Will have bowel movement every three days" and "Will be cooperative with assisted toileting." The interventions to assist with achievement of these goals included, "See nutritional care plan" and "See skin integrity prevention and management plan of care." The stated interventions did not address the identified problem and would not lead to achievement of the established goals. c) Resident #97 1. Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her "pain medications are scheduled". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, "Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). " Another note, dated 01/01/09 at 4:35 a.m., stated, "Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time." A nursing note, dated 01/01/09 at 1:35 p.m., stated, "Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor." There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with "an alteration in comfort related to pain secondary to L (left) shoulder pain." Pre-printed goals were checked for this problem statement as follows: "Decrease persistent pain to a tolerated level so resident can function in daily life"; "Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and "Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity." Also included were the following functional goals: "Participate in ADL's"; "Participate in therapies"; "Will not experience decline in functioning related to pain"; and "Non-pharmacological measures will be used as alternatives to medication when appropriate." The interventions for achieving the goals written above were as follows: "Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN." This care plan was not individualized to address Resident #97's pain. 2. The resident's care plan also contained the following problem statement: "Refer to the physical restraint / enabler assessment." The goal stated: "Will be free of negative effects with the use of an enabler." (There was no mention about how the enabling device was intended to improve the resident's functionality.) One (1) intervention simply stated what device was to be used (1/2 top side rail) to aid in turning and reposition. The only other intervention was "Refer to the mood and behavior symptom plan of care." Review of the mood and behavior plan of care found no interventions related to the use of an enabler. There were no interventions written to assist in achieving the goal established. 3. The director of nursing (DON - Employee #2) was made aware of the inconsistencies in Resident #97's care plan at 10:00 a.m. on 01/08/09. She stated she was aware there were a lot of pages in the care plan, but this was the way their corporation required them to do the care plans. She was made aware that the resident's true problems often could not be identified and the treatment they were to receiving often did not match the care plans. d) Resident #28 Medical record review, on 01/06/09 at 1:32 p.m., revealed Resident #28 was on several medications for moods / behaviors, including [MEDICATION NAME] 12.5 mg via g tube BID (two-times-a-day), [MEDICATION NAME] 0.5 mg via g tube TID (three-times-a-day), and [MEDICATION NAME] 10 mg via g tube QD (every day). Review of the resident's most current care plan, dated 11/26/08, found the facility identified the resident was at risk for depression as evidence by "unhappy behavior symptoms" and persistent anger with self or others. The goal included reduction / elimination of unhappy behavior symptoms. Interventions to achieve the goal included: "offer time to express feelings and concerns; separate from stressful situations; 1:1 (one on one) conversation to maintain trust of staff; offer reassurance; and depression scale q3 (every three) months." Another problem was behavioral symptoms that may be harmful to self or others or interfere with function or care as evidence by yells out loud and grabs, combative with staff. The goal included no injury to self or others. Interventions included: "administer medications, see nsg (nursing) mar (medication administration record), redirect to activity of 1:1 diversion, offer time to express feelings and concerns, separate from stressful situations, redirect to act. or 1:1 act (activity or one-on-one activity) offer to call son." Review of the resident's minimum data set assessment (MDS), dated [DATE], revealed Resident #28 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited repetitive verbalizations, repetitive anxious complaints, sad pained worried facial expressions crying and tearfulness (of which all were easily altered). Review of the behavior tracking report, from 06/01/08 through 11/30/08, found the following: - 06/17/08 - crying and "mood persistence" (each one time). - 07/27/08 - crying - 08/08/08 - crying and "mood persistence" - 08/21/08 and 08/30/08 - crying - 09/02/08 and 09/03/08 - physical abuse (a behavior which was not described) - 10/03/08 - crying - 10/04/08 - crying and "mood persistence" - 10/06/08 - sad / pained / worried facial expression and "mood persistence" - 10/07/08 - crying two (2) times and "mood persistence" - 10/26/08 - crying and repetitive verbal, unrealistic fears, repetitive anxious, sad / pained / worried facial expression, and "mood persistence" - 10/27/08 - crying and "mood persistence" - 11/15/08, 11/21/08, and 11/25/08 - crying and "mood persistence" The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. e) Resident #62 Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several medications for moods / behaviors. Her physician's orders [REDACTED]. - On 10/31/07 - [MEDICATION NAME] tablets 20 mg PO (by mouth) Q AM (every morning) and [MEDICATION NAME] 50 mg po BID; - On 02/20/08 - [MEDICATION NAME] 200 mg PO QD and [MEDICATION NAME] 100 mg PO QD; - On 05/15/08 - [MEDICATION NAME] 5 mg po BID; - On 11/12/08 - [MEDICATION NAME] 0.25 mg PO Q AM, [MEDICATION NAME] 0.5 mg PO Q HS (every night), and [MEDICATION NAME] ER 250 mg PO QD. Review of resident's current care plan, last updated on 10/15/08, revealed the interdisciplinary care team identified Resident #62 exhibited behavioral symptoms that may be harmful to self and/or others or that interfered with function or care, as evidenced by "cognitive deficit Alzheimer's, doesn't understand the need to be here." The goals associated with this problem statement were no injury to self or others and to reduce the frequency of behavioral symptoms. Interventions included: "1:1 conservation to calm, reminisce, see act poc (see activity plan of care), offer to call family." Another problem statement addressed: "Socially inappropriate - yells out loud for nurses to help her. Yells that she's sick or has to go to the bathroom; anxious / repetitive questions, statements." The goal associated with this problem statement was: "Will exhibit socially appropriate behaviors." Intervention included: "offer reassurance, encourage rest encourage activities, separate from stressful situations, offer to call son, take for a walk." Review of the resident's most recent MDS, dated [DATE], revealed Resident #62 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited negative statements, repetitive questions, repetitive verbalizations, unrealistic fears, recurrent statements that something terrible was about to happen, repetitive anxious complaints, [MEDICAL CONDITION], sad / pained / worried facial expressions, crying / tearfulness, and repetitive movements (all of which were not easily altered). Additionally, the assessor identified that the resident exhibited wandering, verbally abusive, physical abusive, and socially inappropriate behaviors and resists care (all of which were not easily altered). Review of the behavior tracking report, from 09/11/08 through 10/10/08, revealed she exhibited behaviors on only four (4) days during the two-month period (09/30/08, 10/06/08, 10/07/08, and 10/10/08). The behaviors being tracked were: negative statements, repetitive questions, repetitive verbal, persistent anger, self deprecation, unrealistic fears, terrible things to happen, repetitive health, unpleasant mood, [MEDICAL CONDITION], sad / pained / worried facial expression, crying, repetitive physical, mood persistence, wandering, wandering altercation, verbal abuse, verbal altercation, physical abuse, physical altercation, socially inappropriate, social altercations, and resists care. Specific examples of these behaviors (such as what constituted "mood persistence") were not identified in either the resident's assessments, care plan, or behavior tracking report. The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. f) Resident # 81 Medical record review (on 01/06/09) of the physical restraint / enabler plan of care, dated 09/24/08, revealed the following problem statement: "Refer to the physical restraint / enabler assessment." The associated goal was: "Will be free of negative effects with the use of the enabler". The plan did not identify the reason for use of the enabler and did not establish a goal based on the assessment and the use of the enabler. . | 2014-02-01 |