| 151 |
HUNTINGTON HEALTH AND REHABILITATION CENTER |
515007 |
1720 17TH STREET |
HUNTINGTON |
WV |
25701 |
2019-10-10 |
657 |
D |
0 |
1 |
RPKM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise care plans regarding falls, behaviors, and Total [MEDICATION NAME] Nutrition (TPN). This was true for two (2) out of thirty-five (35) resident's care plans reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: R#116 and R#94. Facility census: 181. Findings included: a) Resident (R#116) 1. Falls Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. Both times the injured areas were appropriately cleaned and treated; vital signs and neuro checks were completed; and proper notifications were made. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/19, was held to discuss the fall occurring on 8/19/19. The note included the following Intervention: hey therapy (physical therapy referral), neuro-checks, skin treatment/first aid, provider eval with an order for [REDACTED]. Review of R#116's care plan, on 10/09/19 at 10:56 AM, revealed only one revision concerning the fall was made to the care plan after the 1st fall out of the wheelchair. The revision was made on 08/22/19. The revision stated, to have reacher at bedside. A reacher is a reaching extension tool used for grasping items in hard-to-reach places without having to bend over. An interview with RN#96, on 10/09/19 at 11:08 AM, revealed RN#96 confirmed the care plan was not revised appropriately. RN#96 said, The resident did not fall out of the bed, but both times out of his wheelchair, reaching for things on the ground. The care plan should not have limited the reacher to be only at bedside, so it would be available when or where he needed it. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing resident's MDS and care plans, revealed R#116 care plan was not revised as it should have been, to address the issue of the resident falling out of his wheel chair due to reaching for items on the ground. Also, the care plan was not revised with any new or different interventions when the resident fell out of the wheelchair the second time while reaching for items on the ground. 2. Resident (R#116) Behavioral needs Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily and was admitted to the facility on [DATE]. Review of records showed an order for [REDACTED].#116 refused care. Review of the care plan revealed a care area receives antipsychotic medication [MEDICATION NAME] d/t refusal of care r/t [MEDICAL CONDITION]. The care plan did not reveal a care focus area concerning refusing care or any other interventions to address refusing care, such as encouraging, prompting, cueing, or redirecting. Review of the (MONTH) and (MONTH) 2019 medication administration records (MARs) revealed Observation: Antipsychotic Med: Observe for behavior: refusal of care & doc. #of episodes (and document number of episodes). Observe for side effects: (listed side effects) Document 'Y' if resident is free of side effects. 'N' if the resident is not free of side effects. If 'N' document SE (side effects)in the progress notes every shift. Neither month documented the resident refused care. The MAR indicated [REDACTED]. Observations made by Surveyor # and Surveyor # during the initial dining tour revealed R#116 eating his lunch with his face down in his plate using his mouth to eat out of his plate without the use of any eating utensils or his fingers. On 10/09/19 at 10: 44 AM, an interview with Registered Nurse (RN#96) revealed R#116 has behaviors and has a [DIAGNOSES REDACTED].#96 described the resident has verbal outburst; is easily agitated; and has unusual mannerisms like the way he eats with his mouth in his plate. When asked where staff monitors and documents these behaviors, RN#96 said on the MAR (medication administration record) with the [MEDICAL CONDITION] medication. RN#96 denied there was any other behavior monitoring sheet to track identified behaviors other than the MAR. On 10/09/19 at 12:53 PM resident was observed in dining room without participating in lunch. The resident stated he was going to wait until dinner and did not want lunch now. Nursing Assistant Mentor (NA#54) was monitoring the dining room. An interview with Nursing Assistant Mentor (NA#54), who helps train newly hired NAs, revealed she often observes R#116 using unusual eating habits at meals. NA#54 stated she has worked at the facility a few years prior to R#116 being admitted to the facility. NA#54 said since R#116 has been at the facility, she has often seen R#116 placing his face in his plate when eating, she said, He usually does. NA#54 stated, It's like, he likes to sleep in it. If anyone tries to correct him, he will go off. This surveyor asked if R#116 had ever fallen asleep in his food, NA#54 denied ever seeing him sleeping in his plate, but said, It just looks like it sometimes. When asked, How would a newly employeed NA know about his specific behaviors and how they should handle them? NA#54 said grinning, If they try to correct him, they will get an ear full. They should follow the Kardex, it comes from the care plan. This surveyor asked, Is his eating behavior and other behaviors addressed in the care plan? NA#54 replied, I would like to think so. It should be addressed in it. When asked what NAs are trained to do if the resident has an outburst or is agitated, NA#54 replied, They should redirect him and use a calming voice. They should just follow the care plan. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs and care plans, revealed R#116 care plan was not revised to monitor or address his unusual eating habit or different behaviors unique to R#116. Review of care plan revealed a focus area, (Resident's name) is verbally aggressive at times and will curse and yell. The 3 interventions noted in the care plan were Administer medications as ordered. Observe/document for side effects and effectiveness.; Give the resident as many choices as possible about care and activities.; and Psychiatric/Psychogeriatric consult as indicated. There was no guidance to staff on individualized specific strategies that R#116 responds to or works well for the resident. RCMD#165 agreed the care plan needed to be revised to include more individualized and person-centered strategies to address the resident's specific behaviors. b) Resident #94 During a record review, Resident #94's care plan noted the resident received total paranteral nutrition (TPN). TPN is an intravenous (IV) fluid that attempts to provide all the body's need for nutrition without using the gastrointestinal (GI) tract. Review of Residents #94's care plan found a focus/problem: [NAME] will self disconnect TPN from catheter. The goal associated with this problem: [NAME] will have fewer episodes of listed behaviors by review date. Interventions included: -- Allow choices within individual's decision making abilities. -- Anticipate and meet the resident's needs. Focus/problem: [NAME] has a potential fluid deficit r/t (related to) need for TPN. The goal associated with this problem: [NAME] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions included: -- Ensure the resident has access to fluids of choice whenever possible. During an interview on 10/09/19 at 10:48 AM, Employee #165, Care Management Minimum Data Set (MDS) Director, confirmed the resident no longers receives TPN. Employee #165 stated that the care plan had not been updated since the TPN had been discontinued. On 10/09/19 at 11:06 AM, the findings were discussed with the Administrator, the Director of Nursing (DON), and the District Director of Clinical Services. |
2020-09-01 |