cms_WV: 9887
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9887 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-01-08 | 514 | E | 1 | 0 | 0RE212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure accurate documentation for seven (7) of thirteen (13) residents who required bed and/or chair alarms for safety precautions. These residents had no directives on the Treatment Administration Records (TAR) to check the functionality of the alarms. Instead, the TAR directed that alarms were to be used, or nurses "may utilize"alarms. This had the potential to endanger those seven (7) residents by not ensuring clear directives to nursing staff to check and document the functionality of the alarm equipment. Resident identifiers: #55, #18, #35, #85, #62, #26, and #32. Facility census: 87. Findings include: a) Resident #55 An incident and accident report was reviewed on 01/08/14 at 12:00 p.m. This review revealed that on 01/04/14 at 7:45 a.m., Resident #55 was found on the floor by staff. The resident had removed her alarm prior to the fall. The report did not indicate whether it was alarming at or before the time of the fall. Another incident report, dated 01/04/14 at 9:00 a.m., revealed she was again discovered by staff lying on the floor beside her bed. According to the incident report, the alarm did not sound. Staff replaced the alarm at that time. The treatment administration record (TAR) was reviewed on on 01/08/14 at 1:00 p.m.. It directed that staff "may utilize sensor pad alarm to bed at al limes, to alert staff to resident's attempts to transfer unassisted, to minimize falls risk". The start date for this intervention was 12/24/13. Nurses initialed the TAR at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. An interview was conducted with licensed nurse Employee #44 at 1:30 p.m. on 01/08/14. She first checked the TAR, then said there is no order on the TAR for staff to check the functionality of the bed alarm. She said there was someone assigned to check the functionality via daily audits. On 01/08/14 at 1:45 p.m., the administrator was asked how staff demonstrated the functionality of the alarms was checked. She enlisted the Director of Nursing (DON) to answer the question. At that time, the DON said the audit person checks the functionality of the alarms. Beginning 01/01/14, the daily audit checks decreased to three (3) times per week. She said the facility had no policy to check the functionality of alarms daily or per shift. They have a policy to check the WanderGuard functionality every shift. She said they could perhaps suggest at the next Customer At Risk meeting to add to the TAR to check functionality of the alarms daily or every shift. An interview was completed with Nurse #4 at 2:45 p.m. on 01/08/14. She was working with the resident on 01/04/14. She said the alarm was checked at the first fall at 7:45 a.m. and was working, although it was not documented on the incident report or the nurses' notes that it was checked. Staff found her on the floor again at 9:00 a.m. The alarm did not sound at that time. She did not know if the problem was with the batteries or the box itself, so she switched out the whole unit. She was the nurse assigned to check the alarms on all the residents on 01/04/14. She said all resident alarms were checked between 9:00 a.m. and 11:00 a.m. as per schedule on 01/04/14, and all other alarms were functioning properly. On 01/08/14 at 3:00 p.m., an interview was completed with Licensed Nurse #95. She looked at copies of the TAR for Residents #55, #35, #18, #85, and #29, each of whom did not have written orders to check the functionality of their alarms. Each had a place with nurse initials twice daily for the alarms. She said that to read it, the TAR order signifies to her by nurse signatures that the devices are in place for each of those residents, although the orders do not direct to check the functionality. She said had she been the nurse on those days, she would have checked the functionality at the same time she checked placement, even though not specifically directed to do so. An interview was completed with Licensed Nurse #103 at 3:20 p.m. on 01/08/14. She said she checked placement and functionality of the alarms for Residents #26 and #62 that morning. She agreed that the TAR order did not direct her to check the functionality of the alarms for those two (2) residents, but she did so anyway. At 3:30 p.m. on 01/08/14, an interview was conducted with the administrator, Nurse Consultant #104, and the DON. The administrator said most of the nurses check functionality when they check for placement of the alarms, even when it is not written for them specifically to check the functionality. She said they would correct this issue to ensure that each TAR of all residents with alarms included to check functionality and placement every shift. She agreed that checking the functionality of all the alarms was not documented. Nurse Consultant #104 said she could not say for sure if the evening shift nurse had checked the functionality on this resident's bed alarm on 01/03/14. She agreed that it was not documented as having been checked. A sweep was then made of all the residents in the facility who had alarms. Each alarm was checked for functionality, and all were found to be functioning adequately at that time. b) Resident #18 Review of the TAR on 01/08/14 found an order for [REDACTED]. It was initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. There was no evidence of any functionality checks of the alarm during this time frame except for an audit dated 01/04/14. c) Resident #35 The TAR was reviewed on 01/08/14. There was an order for [REDACTED]. There was no evidence of functionality checks of the alarm during this time frame except for an audit dated 01/04/14. d) Resident #85 Review of the TAR, on 01/08/14, revealed an order for [REDACTED]. It was initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. There was no evidence of a functionality check of the alarm during this time frame except for an audit dated 01/04/14. e) Resident #62 The TAR was reviewed on 01/08/14. There was an order for [REDACTED]. Another order stated "Resident to have tabs unit while in bed Start Date: 10/14/2013 Night Shift, Day Shift Everyday". These orders were initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. There was no evidence of functionality checks of the alarm during this time frame except for an audit dated 01/04/14. Another order on the TAR stated "Res (Resident) to have WanderGuard at all times, nursing to check placement and function every shift. . . Start Date: 10/29/13 Night Shift, Day Shift Everyday". This order was initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. f) Resident #26 Review of the TAR on 01/08/14 found an order which stated "Resident to have sensor pad on bed. Start Date: 1/2/2014 Night Shift, Day Shift Everyday for history of falls". Another order stated "Resident to have TABS unit on when up out of bed. Start Date: 1/2/2014 Night Shift, Day Shift Everyday D/T (due to) history of falls". These orders were initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. There was no evidence of functionality checks of the alarms during this time frame except for an audit dated 01/04/14. g) Resident #32 The TAR was reviewed on 01/08/14. There was an order for [REDACTED]. This order was initialed by nurses at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. There was no evidence of functionality checks of the alarm during this time frame except for an audit dated 01/04/14. . | 2015-08-01 |