| 9403 |
RIVER OAKS |
515120 |
100 PARKWAY DRIVE |
CLARKSBURG |
WV |
26301 |
2010-04-08 |
280 |
D |
0 |
1 |
85AT11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed, for three (3) of thirty-seven (37) Stage II sample residents, to update the plan of care to reflect current needs. Resident #153 experienced a decline in urinary continence with no update to the plan of care, Resident #158 experienced a fall with no update in the plan of care, and Resident #160 experienced a change in the status and treatment of [REDACTED]. Resident identifiers: #153, #158, and #160. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this resident, stated the resident was almost totally incontinent and would only occasionally ask to go to the bathroom. These findings were bought to the attention of the director of nurses (DON) and assistant director of nurses (ADON) on 04/08/10 at 10:00 a.m., and the facility could provide no evidence to reflect revisions had been made the resident's care plan to address her urinary incontinence. b) Resident #158 When reviewed on 04/01/10, the care plan for Resident #158, who was admitted to the facility on [DATE], disclosed the facility, on 01/13/10, identified the resident to be at risk for falls due to use of [MEDICAL CONDITION] medications, impaired balance / poor coordination, history of falls. Further review of the resident's medical record revealed [REDACTED]. The care plan was not updated at that time to reflect additional interventions to prevent further falls. The ADON (Employee #32), when interviewed on 04/07/10 at 11:00 a.m. about the resident's fall and interventions that had been implemented following the fall to prevent further falls, stated it was believed the resident's friend had attempted to assist him to transfer at the time of the fall. This friend had been educated at that time to call for staff assistance instead of attempting to help him herself. The ADON further confirmed the resident's current care plan did not contain any of this information to alert other staff caring for the resident about the problem should it happen again. c) Resident #160 Medical record review, on 04/05/10, revealed this [AGE] year old male was admitted to the facility on [DATE] with a Stage II pressure ulcer. On 02/23/10, the wound care clinic was consulted, since the wound was not showing any progression toward healing. On 03/23/10, the wound care clinic identified the needs to keep weight off the resident's coccyx at all times by using a waffle cushion in the wheelchair, to limit the amount of time sitting in a chair, and to reposition the resident every two (2) hours when in bed. Additional review of the medical record revealed the wound care clinic made several changes in the care / treatment of [REDACTED]. On 04/07/10 at 11:24 a.m., the dressing change procedure was observed, and the nurse reported the wound care clinic had changed the treatment to wash with soap and water, pat dry, and apply antifungal ointment. On 04/06/10 at 10:00 a.m., Resident #160, when interviewed in his room while in bed, reported he believed the wound care clinic had really helped, they had made several changes, to the treatment to be completed, and he had been told the ulcer was healing up pretty good. A review of the resident's comprehensive care plan, on 04/05/10, revealed the plan addressing the resident's pressure ulcer had not been updated to reflect changes in treatment made by the wound care clinic. Current care plan interventions included: apply skin care moisturizers as needed; encourage and assist as needed to turn and reposition frequently; evaluate and record wound status per facility guidelines until healed; observe for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc.; Easy Air mattress to resident bed; supplements / enhanced or fortified foods per physician orders; and physical therapy referral and treatment as ordered by physician. On 04/10/10 at 3:26 p.m., the assessment coordinator (Employee #105), when interviewed, reported the wound care nurse was responsible for assessing the wounds and revising the care plans as needed. She identified the wound care nurse was off on sick leave and was not able to be interviewed at this time. On 04/07/10 at 9:30 a.m., the DON produced a copy of the facility's policy and procedure for wound healing. Review of this policy revealed that, on page 10 related to the comprehensive plan of care: Based upon the findings of the MDS, pressure ulcer RAP and other assessments, the initial care plan is updated and comprehensive care plan is developed. When the interdisciplinary team develops or updates the patients care plan a measurable goal is determined and a target date identified. Individualized interventions are selected based upon the current clinical condition risk factors, functional status and the patients values, goals and willingness to participate with the plan of care. The care plan is reviewed and updated to reflect the patients current status and care delivery needs, as clinically indicated and per state and federal regulations. There was no evidence the facility revised Resident #160 care plan as needed when changes in treatment occurred. |
2015-11-01 |