cms_WV: 9212
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9212 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 323 | G | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents and to promote resident safety. The facility failed to assess the immediate safety needs for Resident #228, a newly admitted resident who was identified in her admission information as having dementia and a history of falls. Failure of the facility to assess the resident upon admission for safety needs and to implement measures to prevent falls resulted in the resident falling only six (6) hours after she arrived at the facility and sustaining a head injury. She was transferred to the emergency room and treated for [REDACTED]. After safety measures were ordered upon her return to the facility (to include a low bed without side rails and mats on both sides of her bed), she was observed in her bed with a mat on only one (1) side of bed and tile floor on the other side. Resident #76, who had a [DIAGNOSES REDACTED]. He was in a low bed, and according to his treatment record, he was to have mats on both sides of the bed. Two (2) mats were stacked on top of each other on one (1) side of the bed with the tile floor on the other side. Resident #48 was observed to have Theraband used in a manner that was presented an accident hazard to this cognitively impaired resident. This band, which had been tied to the wheelchair to secure her leg secured to the chair, presented a hazard when the resident attempted to stand up from the chair without assistance. Resident #5 was observed at meal time to have straws in beverages, which were contrary to his physician's orders [REDACTED]. This was an accident hazard for this resident. Failure of the facility to assess the residents for safety needs and implement measures to prevent accidents and injuries affected three (4) of thirty-eight (38) Stage II sample residents. Resident identifiers: #228, #76, #48, and #5. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 A complaint investigation was initiated at this facility at 12:00 p.m. on 05/18/11. Observation, at this time, found Resident #228 in her room. The resident was seated on a low bed with one (1) mat on the floor on the right side of her bed by the window. She was reaching over to feed herself from her meal tray, which was sitting at bedside on a small isolation cart with rollers. There was no a mat on the floor on the left side of her bed. She had dried blood on her laceration just above her left eye, bruising surrounding the eye, and facial swelling involving the area around the eye. She also had a hematoma on her forehead. She was very pleasant and was eating lunch at that time of this visit. When asked about her eye, she stated she fell while trying to pick up a bag of birdseed. - Review of Resident #228's medical record revealed this [AGE] year old female was admitted to the facility at 8:30 p.m. on 05/17/11. According to hospital records provided on admission, this resident had dementia and a history of falls. That she had frequent falls was also noted on her physician's admission orders [REDACTED] According to the medical record, this resident was admitted to the facility at 8:30 a.m. on 05/17/11. Her admission note recorded her vital signs, weight, and height and stated the dietary department and the pharmacy were notified of her admission and her medications were ordered. The physician's orders [REDACTED]. The note stated: Will cont (continued) to monitor. There were no further entries in the resident's nursing notes, there were no assessments on file, and there was no evidence to reflect that any safety measures had been implemented. According to the nursing notes dated 05/18/11 at 2:30 a.m., Resident #228 was found face down in the floor in her room with blood on her right hand and on the left side of her forehead; she was subsequently transferred to the hospital for evaluation due to complaints of pain in her left leg. The resident was in this facility for a total of six (6) hours prior to falling and being transferred to the hospital. She subsequently returned to the facility at 6:00 a.m. on 05/18/11. The hospital emergency department notes, when reviewed, indicated the resident arrived at the hospital with signs of head trauma present. Her forehead was tender with a small abrasion. She had facial swelling present involving the area around the left eye. She had a small abrasion to the left cheek and a small abrasion to the left lower eyelid. Her left eyebrow area had a 1.0 cm laceration with controlled bleeding. The resident's wound was repaired with skin adhesive. There were not complications. She had a CAT (Computerized Axial Tomography) scan of the head. The resident was then transported back to the nursing home. The nursing notes upon her return to the facility, dated 05/18/11 at 4:45 a.m., stated: Notified POA of residents return. The next note, written on 05/18/11, stated (quoted as written), The resident arrived (name) hospital at 0630 (6:30 a.m.) via ambulance. Resident left eye has a hematoma cut to left eye is bleeding. Resident is talking refused to put ice on her eye for swelling. This was the last entry in the nursing notes when this surveyor reviewed the resident's medical record at 1:30 p.m. on 05/18/11. Based on record review and staff interviews, there was no evidence that direct care staff had been made aware of the resident's risk for falls when she arrived at the facility (in view of her previous history of falls), and there were no evidence to reflect safety measures were implemented by staff to address her immediate care and safety needs until a comprehensive assessment could be completed. Employee #93 (nursing assistant) was interviewed, at 1:00 p.m. on 05/18/11, about how he was made aware of the immediate needs of newly admitted residents. He stated they have a care plan sheet on which the care interventions were written for every resident. He went to the nurses' station and showed this surveyor the care plan sheet. Review of this sheet found no mention of Resident #228. Employee #93 stated they still had the name of the resident who used to be in that room on the sheet and they had not added Resident #228 to it yet. He said usually they added new people and her care needs should have been on here. During an interview with a registered nurse (RN - director of care delivery Employee #104) on 05/18/11 at 2:00 p.m., she was asked how the immediate care needs for newly admitted residents were communicated to the direct care staff. She verified that Resident #228 was not on the care plan sheet, that the sheet contained the name of the resident who previously occupied her bed, and that this had not been changed yet. At this time, eighteen (18) hours had passed since Resident #228's admission to the facility. Employee #104, when questioned how often the care plan sheet was updated, said it was printed each morning with changes. However, this resident had not been added to the form and she was admitted at 8:30 p.m. the prior evening. Employee #76 (nursing assistant) was interviewed the afternoon on 05/18/11; she was providing care to Resident #228 at that time. She was questioned about how she was made aware of the immediate care needs for newly admitted residents, including measures to promote the safety of residents at risk for falling. She stated this facility did not use alarms or side rails because it was against the state law and they just do the best they can. Employee #104 was observed, at 5:00 p.m. on 05/18/11, to be completing a care plan for this resident's immediate care needs. She verified there had been nothing written prior to this time, and she could not provide any evidence to show that staff members assigned to provide care to Resident #228 had been made aware of her risk for falls and/or the need for supervision, prior to her fall that resulted in her being sent back to the hospital. She verified that the safety interventions now in place for this resident (low bed and the bilateral landing strips on the floor beside the bed) were initiated after the fall that resulted in her emergency room visit. She also verified that there was no immediate or interim care plan or physician's orders [REDACTED]. When she was made aware that there was only one (1) landing strip beside the resident's bed, she obtained another one (1) for the resident's safety. -- b) Resident # 76 Observation, on 05/31/11 at 1:30 p.m., found Resident #76 in a low bed. He had a feeding tube, a below the knee amputation, and a tracheostomy. There were no side rails on his bed, and two (2) mats (landing strips) were stacked on top of each other in the floor on the resident's left side of the bed by the window. The nurse administering his medications at that time (Employee #100) was questioned about the mats being on top of each other and asked if there should be one (1) mat on each side of the bed. She stated she did not know, because she was new to this unit. She stated they (the mats) were that way this morning, and this was how she had always seen them. The nurse administered the resident's medication and did not move the mats to provide safety to this resident, nor did she check his medical record to see how these mats were to be used. She stated at that time that she would have to check on that. The medical record was reviewed, and the resident's medications were checked. At this time, it was noted that this resident's [DIAGNOSES REDACTED]. Employee #100 was questioned again about the mats at 2:30 p.m. on 05/31/11. It had been one (1) hour since the initial observation of these mats being found on only one (1) side of the resident's bed. The nurse said she forgot to check. She looked in the resident's record and stated, You are right. They should be on both sides of the bed. She then went into the resident's room at that time and moved one (1) of the mats to the resident's right side of the bed, so he would have padding on the tile floor on both sides of the bed. -- c) Resident #148 During the initial tour in Stage I of the survey on 05/24/11 at 11:15 a.m., this resident was observed seated in a wheelchair in the hallway on C-Wing. The resident had a yellow Theraband (stretchy therapy band) tied to her wheelchair and attached to her right foot. The device was knotted in several places to make it short, and had a loop on the end in which to place the resident's foot. The device did not appear to be a product designed to be used in this manner, instead it appeared to be something rigged to suit a purpose. During the observation, the resident attempted to stand several times. Fortunately, she had squirmed around in her wheelchair enough that her foot had slipped out of the Theraband before she attempted to stand. However, the resident did not have the cognitive ability to purposefully remove her foot from the device so it would not cause a fall when she attempted to stand. Since the resident made attempts to stand, the Theraband (when attached to her foot) presented an accident hazard. At 11:40 a.m. on 05/24/11, an interview was conducted with a licensed practical nurse (LPN - Employee #8), who stated, Therapy puts it on her foot to keep her from dropping her leg. Employee #8 looked at the resident's treatment records and stated there was nothing in those records regarding the use of this observed device. - The resident was reviewed during Stage II of the survey. At 10:45 a.m. on 06/08/11, an interview was conducted with Employee #110 (the rehabilitation services manager) and Employee #200 (a physical therapist). Employee #200 stated she had decided to use the device and had applied it to the resident and the wheelchair. Further interview revealed the resident had a total hip replacement. The surgery later had to be redone. Employee #200 stated, After the surgery the whole leg was rotating, and she does not have cognitive ability to maintain hip precautions. For these reasons, Employee #200 stated she decided to use the Theraband in this fashion. When asked if this was a recommended use for a Theraband, Employee #200 stated, I have seen other therapists do it at other places. At that time, Employee #200 was informed about the resident's attempts to stand on 05/24/11. Employee #200 stated she was not aware the resident was able to stand and was not aware of her attempts to do so. - Medical record review, on 06/08/11, revealed no assessment or care plan for any device to maintain hip precautions. Employees #110 and #200 were asked if there were any therapy notes and/or orders for this device. At 10:45 on 06/08/11, Employee #110 stated there were no progress notes, physician's orders [REDACTED]. - The facility had not used results of a comprehensive assessment to develop a care plan for this resident regarding her need to maintain hip precautions, and at the same time prevent avoidable accidents. The hazards and risks of using a device which restricts the movement of a foot, especially for a cognitively impaired resident, were not identified. There was the potential for an avoidable accident because the facility failed to identify this resident's individual risk of an accident. The Theraband, as used, was an accident hazard over which the facility had control. The facility failed to assess this resident's individual needs and risks regarding the use of the Theraband in this manner. -- d) Resident #5 After lunch on 05/26/11, the resident was observed lying in bed drinking her afternoon nutritional supplement. She was drinking from a straw inserted into a small carton of supplement. The head of her bed was elevated at only approximately 30 degrees. This posed a potential for increased risk of aspiration. Observation, on 05/31/11 at approximately 2:00 p.m., found the resident lying in bed holding a carton of supplement with a straw. The head of her bed was elevated at only approximately 30 degrees. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. A cup with a straw and a small carton of supplement with a straw were at her bedside. The resident was elevated at only approximately 20 degrees. Subsequent observations throughout the day on 06/01/11 and 06/02/11 found she had straws in her beverages and was not positioned in an upright position. A speech therapist had evaluated the resident on 02/15/11. The therapist had noted the resident needed to be in upright position. Review of the physician's orders [REDACTED]. | 2016-01-01 |