cms_AK: 2
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 |
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2 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 241 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide cares and services in a manner that maintained and promoted dignity for 3 residents (#'s 5, 14 and 15). Specifically, the facility failed to: 1) ensure personal care was provided in a manner to promote dignity and comfort for 1 resident (#5) out of 5 residents observed during personal cares, and 2) removed gait belts (devices used by caregivers to transfer residents with mobility issues from one position to another, from one location to another or while ambulating residents who have problems with balance) for 2 residents (#'s 14 and 15) out of 5 observed during a group meeting who required gait belt use for transfers. These failed practices had the potential to negatively affect the residents' self-esteem and quality of life. Findings: Personal Cares: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as needing extensive assistance with 2 persons for bed mobility, dressing and personal hygiene. Observation on 5/16/17 at 11:18 am, revealed certified nursing assistants (CNA) #s 1 and 2 provided morning cares to Resident #5. During cares, CNA #2 rolled the Resident to the left side exposing his/her buttocks and genitals. During the observation CNA #2 left the bedside multiple times to obtain various items such as clothing, mechanical lift and sling. The CNAs did not cover the Resident while CNA #2 left to get supplies. As a result, the Resident was exposed while waiting for staff to obtain supplies. Observation on 5/16/17 at 12:27 pm revealed CNA#s 1 and 3 were dressing Resident #5. During the observation both CNAs raised Resident #5's legs off the bed approximately 12 to 14 inches to place the Resident's pants on each leg. The Resident began to rapidly swing his/her upper right arm and meaningfully grimaced and attempted to yell in discomfort. Neither CNA noticed the Resident's reaction to the Activities of Daily Living (ADL) until prompted by the Surveyor. During an interview on 5/17/17 at 2:49 pm the Administrator stated staff should cover residents during cares to decrease unnecessarily exposure. In addition, the Administrator stated staff should always be mindful of residents' response to cares and find adaptations to cares if causing pain. Gait Belts: Resident #14 Record review from 5/17-19/17 of Resident #14's care plan, dated 5/17/17, revealed .Resident needs FWW (front wheeled walker) with gait belt and stand by assist for ambulation. Observation during a group interview on 5/17/17 from 9:00 am to 9:40 am revealed Resident #14 arrived ambulating with a walker and had a gait belt on. The Resident sat in a chair during the meeting and had the gait belt on during the entire meeting. Resident #15 Record review from 5/17-19/17 revealed Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment dated [DATE], revealed the Resident was coded as needing extensive assistance with locomotion and limited assistance with transfers. Review of Resident #15's most recent care plan, dated 4/20/17, revealed .Assist/supervise with transfers and ambulation Continuous observation on 5/17/17 from 9:05 am - 9:50 am revealed Resident #15 wearing a gait belt around his/her waist throughout the entire Resident group meeting. During an interview on 5/17/17 at 2:15 pm, CNA #s 3 and 4 stated gait belts should come off when not being used. During an interview on 5/19/17 at 10:10 am, the MDS Coordinator stated she understood the gait belts should come off when not transferring the Resident. Review on 5/16-19/17 of New Horizon Transitional Care Unit .Resident Rights and Responsibilities, revised 3/31/17, revealed .You have the right to .Be treated with consideration, respect and dignity . | 2020-09-01 |