cms_WV: 8542
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8542 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 323 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement interventions to protect two (2) residents with a history of falls. (Residents #51 and #28) 1. The facility failed in multiple areas, specifically: A. Therapy did not evaluate Resident #51's functional abilities after either the first fall or the second. B. Environmental services had arranged the resident's room for safety, however observations revealed both sides of the bed remained cluttered with equipment, even on the fall mats. C. The care plan had not been updated to include the fall on 03/17/12, thereby preventing the facility from providing interventions which might have prevented the second fall where the resident experienced head and facial injuries. D. Food products were kept on the nightstand, but not within reach of the resident, thereby creating a potential for additional falls should the resident reach for a food product that was out of reach. The findings were: a) Resident #51 This resident was re-admitted to the facility on [DATE]. Review of the 11/07/11 MDS revealed sample Resident #51 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #51's functional status was coded as requiring extensive assistance for ADLs and total assistance required for toileting, hygiene and bathing. She was coded as unsteady with transfers, had range of motion impairments, and was incontinent of bladder and bowel. Resident #51 was 66 inches tall and weighed 155 pounds. Further review of the MDS identified that the resident had experienced no falls since readmission to the facility on [DATE]. The most current MDS, dated [DATE], identified no falls since admission. During the staff interview, on 04/23/2012 at 10:32 a.m., staff identified that Resident #51 had experienced a fall on 04/16/12. The nurse being interviewed identified that the resident had fallen out of bed on the evening of 04/17/12 with resulting bruising to the face. The nursing note indicated the fall had been unwitnessed. The resident fell out of bed and was found face-down on the floor on the left side of her face. The resident was transferred to the hospital for an evaluation. The resident returned to facility at 11:47 p.m. Review of the computerized physician's order for April 2012 identified the resident's rehabilitation potential as fair. Additionally, the resident had orders for both a bed alarm and a chair alarm. Both devices were to be checked each shift for function and placement. The bed alarm was to be used at all times the resident was in bed to remind the resident to call for assistance prior to rising. Review of the incident reports related to the fall revealed the resident had experienced an earlier fall on 03/17/12 at 7:00 p.m. The report stated that the resident's roommate had been yelling. A nursing assistant (NA) went to the room and found Resident #51 lying on the floor beside her bed. Resident #51 had been in bed prior to the fall. Ice was applied to a lump on the right side of the resident's head and to a reddened area on the right side of the back. The resident denied pain. Documentation indicated that the personal alarm had been in use. Vitals were documented (BP 128/76, T 98, P 76, R 24). Review of the incident report, dated 04/16/12, revealed a nurse had been called to the room by a NA. The resident was found lying face down on the left side of the bed. The resident had been in bed with the head of bed elevated prior to the the fall. A description of the injury included a hematoma with laceration above the right eye, laceration between nose and right eye, laceration above upper lip. The resident had possibly been trying to reach into the night stand drawer. Review of the care plan revealed that while numerous falls prior to the resident's readmission (03/12/09, 12/30/09, 06/28/10, 07/27/10, 08/06/10, and 04/16/12), were recorded on the care plan, the 03/17/12 fall had not been added to the care plan. Therefore, no reassessment nor interventions following the 03/17/12 fall had been developed to address the resident's increased risk for falls. Review of the care plan revealed numerous interventions that had been initiated on 03/16/08 and 07/01/08, including : Assess changes and report to MD Bed alarm to alert staff of resident's need to ambulate Remind resident to call for assistance when ambulating to bathroom Meds evaluated as needed PT/OT eval as needed Place call light within reach and remind resident to use call light when attempting to ambulate Monitor for and assist with toileting needs Provide verbal cues for safety and sequencing when needed When resident is in bed, place all necessary personal items within reach Additionally the Care Plan identified the resident's need for extensive/total assist with ADLs, total care needed with toileting, incontinence, bed mobility, and transfers. On 04/17/12, the care plan was revised to add bilateral mats to the resident's bedside. Additional Interventions/Preventive measures added to Care Plan included a notification to therapy regarding a reassessment and a notification to environmental services to assess the room for safety. The resident was started on Avelox and Rocephin for an upper respiratory infection. The Interdisciplinary team met for a resident review on 02/01/12. The committee concluded the resident, Has had no falls since 2010. That conclusion was inaccurate; the March fall, just one month earlier, had not been considered. A fall risk assessment had been previously conducted on 11/17/11, and again on 02/01/12. On both assessments the resident scored an 8. A score of 10 or greater indicates that the resident was at high risk for falls. No fall risk reassessment had been completed after the 03/17/12 fall. Environmental services personnel arranged the resident's room, but observations during survey revealed equipment was placed on both sides of the bed, even on the fall mats, creating more of a hazard. Observations: Observation of the resident, on 04/24/12 at 8:00 a.m., revealed her sitting in bed with a food tray. On the right side of the bed was the resident's oxygen concentrator. On the left side of the bed was the resident's bedside table plus her wheelchair was next to the bed on the landing pad provided for resident safety. Observation at 11:30 on 04/24/12, revealed the resident sleeping with the head of the bed at 90 degrees. The resident was sitting straight up in bed. On the right side of the bed was the resident's oxygen concentrator. On the left side of the bed was the resident's bedside tray table plus her wheelchair was next to the bed on the fall mat and her nightstand Observation on 04/25/12 at 8:30 a.m., revealed Resident #51 sitting up in bed with breakfast tray. On the right side of the bed was the resident's oxygen concentrator and her wheelchair was on the fall mat. On the left side of the bed was the resident's tray table (on the fall mat) plus her nightstand. On 04/25/12 at 1:30 p.m., the resident's wheelchair was on the fall mat on the right side of the bed as well as the oxygen concentrator also on the right side of the bed, a tray table was partially on the fall mat on the left side of the bed plus the night stand. Observation of the resident's room on 04/26/12 at 8:15 a.m. revealed the resident's bed was in the low position, her wheelchair was on the fall mat and the oxygen concentrator was on the right side of the bed. The resident had the left side rail up and her tray table was on the fall mat on the left side as well as the night stand. If the resident attempted to get to her snacks, she would have the side rail plus her bedside table and the night stand preventing access to her snacks. Interviews: During an interview with the therapy supervisor, on 04/25/12 at 9:40 a.m., he stated, We investigated it but did not do an evaluation because it was a nursing issue. (There was no evidence of the investigation). We interviewed a NA and since she rolled out bed, determined no functional issues. With the second, we did the same thing and again since she rolled out bed, determined no functional issues. It is not a therapy / function issue. The supervisor was asked if they recommended safety devices. He stated, Therapy would not recommend devices like safety devices. During an interview with the DON at 10:30 on 04/25/12, she stated, We talked about devices, but that's why we referred her to therapy to recommend a device, if needed. During an interview with the unit manager, on 04/25/12 at 10:40 a.m., she stated, the (resident) is on a hi-lo bed, a perimeter mattress is a restraint so we didn't want to do that. We talked about other things. I think it is a combination between her COPD, being anxious and her sun-downing. When she is feeling better, she is up and around the building. We don't want to decrease that. Nurse #1 stated on 04/25/12 at 1:30 p.m., the family brings in candy and puts it inside the nightstand drawer. The resident is paralyzed on the left side, I think she reached across her body to get the candy bars with her right hand and lost her balance and fell . She had her glasses on and was face down on the floor. The w/c and oxygen concentrator were on the right side of the bed. She fell off the left side of the bed, where her nightstand was. Observation at the same time, revealed crackers stored in a plastic container on top of the night stand, canned goods, including soup and peanut butter were stored inside the cabinet. The resident was asked if she liked crackers and peanut butter? Her eyes widened, she smiled and said Yes! Additional observations found a wheelchair on the fall mat on the right side of the bed, as well as, the oxygen concentrator also on the right side of the bed. A tray table was partially on the fall mat on the left side of the bed plus the night stand. A NA stated on 04/25/12 at 1:35 p.m., that she often sees Resident #51 trying to reach her snacks. At 2:45 on 04/26/12, the unit manager, responsible for the care of Resident #51, was questioned about the equipment next to the bed and on the fall mat. She responded, Unless we store the wheelchair there is no other place for it. We can look at it again. I would want her to have her food. The unit manager was asked about the night stand being back behind the bed far enough that her snacks were not within reach. She stated, We'll have to look at it again. b. Resident #28 This resident was admitted to the facility on [DATE]. The resident's nursing assessment, dated 03/30/12 documented the resident had experienced a fall in the past 6 months with a fracture. The medication administration record (MAR)documented the resident was currently receiving an antihypertensive medication, a sedative, and a diuretic. The assessment documented the resident required the assistance of two (2) staff for bed mobility. The resident was chair bound, could not bear her own weight, and frequently slid down in her chair. Further documentation revealed the resident had impairment on her left side upper extremity, weakness in the right and left arm, and her right and left legs. Review of the most recent care plan revealed no use of bed rails on the resident's bed. The care plan did indicate that the resident was at risk for falls and had experienced a recent decline in cognition. Observation on 04/24/12 at 7:50 a.m., revealed Resident #28 was in bed on her back with bilateral half rails up on her bed. There were large gaps from the end of the top rail to the head of the bed. These gaps were large enough for the resident to become entrapped if she attempted to get out of the bed on her own. The resident was observed, on 04/24/12 at 9:30 a.m. and at 1:30 p.m., to be in bed with bilateral half rails up on the bed with gaps noted from the top of the rail to headboard. On 04/25/12 at 8:05 a.m., the resident was observed to be in bed eating breakfast with bilateral half rails raised and gaps were observed from the top of the bed to the top of the rail. Interview with the charge nurse on the North hall, on 04/25/12 at 9:45 a.m., verified there were no physician orders for the use of bed rails. The charge nurse provided a form located in the ADL book that documented the resident did not use bed rails on her bed. This form also documented that the resident was capable of getting out of the bed on her own. There was no evidence of a physician order for [REDACTED]. This was verified by the charge nurse on 4/25/12 at 9:50 a.m. Interview with nurse aide #1, the nurse aide responsible for the care of Resident #28, on 04/25/12 at 10:15 a.m., revealed that she was not sure how long the resident had been using the bed rails on her bed. She stated the only time the resident used them was when the staff were providing care to her. She stated a few months ago the resident was actually able to get out of bed on her own, but she has had a decline and she can no longer get out of bed without staff assistance. With the recent documentation of the resident's decline in cognition, an assessment indicating that the resident was at a high risk for falls, and a recent fall which resulted in a fracture, the resident was at risk for potential entrapment due to the large gaps from the end of rail on her bed to the headboard on her bed. | 2016-05-01 |