| 566 |
YUKON KUSKOKWIM ELDER'S HOME |
25037 |
1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 |
BETHEL |
AK |
99559 |
2018-02-02 |
840 |
E |
0 |
1 |
B1D811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to utilize outside resources from therapies, in a timely manner, to assist with assessment of residents function and help develop individualized care plans for 4 residents (#s 1; 14; 15; and 16) out of 12 sampled residents. The failure to ensure therapies was an integral part of the interdisciplinary team (IDT) placed residents at risk for injuries and functional decline and/or lack of improvement. Findings: Resident #1 Record review on 1/30-2/1/18 revealed Resident #1 had [DIAGNOSES REDACTED]. Observation on 1/28-2/1/18 revealed Resident #1 utilized a wheelchair for mobility. The Resident's right arm was in a sling and positioned at a 90 degree angle across his/her chest. During an interview on 1/30/18 at 8:52 am, Resident #1 stated he/she had fallen out of a wheel chair when trying to look out the window. The Resident stated the fall had broken his/her arm. On 1/30/18 at 3:31 pm, while participating in a bowling activity the Resident fell out of the wheelchair and hit his/her head. 2/01/18 at 8:30 am 3 CNAs (certified nursing assistants) were discussing resident's fall two days ago. the staff stated the Resident was participating in bowling activity and was holding his broken arm still. When he threw the ball, he lost balance in his chair and tumbled forward out of his chair and bumped his head. Further review of the medical record revealed the Resident had not been evaluated by PT ,after the first fall more than 2 weeks ago, for safety in positioning and/or a review of Resident #1's strengths and weakness in an attempt to mitigate further falls. Resident #14 Record review on 1/31-2/1/18 revealed Resident #14 had [DIAGNOSES REDACTED]. During an interview on 1/29/28 at 1:49 pm, Resident #14 stated he/she doesn't get to practice walking enough, adding the staff will complain they are too busy. Review of the most recent MDS quarterly assessment, dated 1/12/18, revealed the Resident had walked in his/her room with support from 1 staff and had walked in the corridor 1 time, during the 7 day assessment window. Review of the CORP-Messages Detail Report, utilized by the CNAs to provide care, revealed (Resident #14) may use the exercise equipment in the MDS office .is on short list for Physical Therapy. If they have a cancellation they will call the Charge Nurse and see if (Resident #14) is available for PT. Review of the Resident's exercise program, undated, revealed Resident #14 was to walk the length of the parallel bars .free range pulleys-3 minutes. 3) Transfer to Nustep (a sit down elliptical type machine) using Hoyer lift. Review of the Resident's care plan Long Term ADL Function Rehab IP[NAME], revised 12/5/18, revealed the interventions: (Resident) uses a wheelchair for ambulation (he/she) cannot bear weight .is on the short list for PT @ the Hospital. Resident #15 During an interview on 1/30/18 at 3:11 pm, Resident #15's family member stated the Resident needed PT for a broken hip. Record review on 1/31-2/1/18 revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. (neurological disease that can cause immobility and/or repetitive movement). After a recent [MEDICAL CONDITION], the Resident had surgical repair and therapy. Review of the Resident's IP[NAME] dated 12/22/17, revealed no specific problems, interventions or goals aimed at maintaining or improving ROM or mobility. Review of the Resident's Individualized Exercise Programs to be Used in Therapy Room, for Resident #15, dated 6/7/17, revealed the Resident was to walk the length of the parallel bars (located in the PT room) 3 times and do free range pulley exercises for 1 minute. The handwritten plan, developed by PT had not been implemented, or reevaluated for effectivnes. Resident #16 Further record review revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. During an interview on 1/29/18 at 4:22 pm, the family member stated Resident #16 was admitted to the facility after surgical repair of a [MEDICAL CONDITION]. The Resident's family member stated the Resident used to walk prior to the fracture. The family member stated the Resident needed PT to get better. The family member stated he/she had been told by the IDT that he/she would need to call the hospital and arrange an appointment and transportation for the Resident to receive PT as PT is not available in the facility. During an interview with the MDS Nurse on 1/30/18 at 12:37 pm he/she stated that there were not enough PT services in the community to meet the Residents' needs. She stated new appointments were months out and that the facility had arranged to fill no show appointments for Residents who really need it. If a PT patient, no showed for an appointment, they would call the facility to see if a Resident could come over and be seen. During an interview on 1/31/18 at 10:28 am, Resident #16's power of attorney (POA) revealed the Resident was admitted to the facility after sustaining a [MEDICAL CONDITION] that required surgery where pins were placed to repair the fracture. Based on an increased level of care required, the assisted living home the resident had previously resided was unable to provide the level of care needed. The Resident consequently was admitted to the LTC facility with the understanding he/she would receive interventions to improve mobility and/or prevent further decline. The POA stated he/she was worried about the Resident's decline. Review of the Resident's IP[NAME], dated 5/12/18, revealed Resident #16 had the problem Alteration of Physical Mobility. No interventions or goals aimed at maintaining or improving functional ability and/or ROM. Review of the Resident's Individualized Exercise Programs to be Used in Therapy Room, developed by PT, revealed Resident's individualized program and not been implemented by the facility and/or reassessed by PT. During an interview on 1/31/18 at 3:25 pm, when asked how they knew what exercises to do for each Resident, CNA #s 2 and 3 stated they just look in CareTracker or just do it. Both CNAs stated they do at least 15 minutes then document how the Resident tolerated it During an interview on 2/1/18 at 9:35 am, when asked what exercises or completed for each Resident, CNA #12 stated it's mostly up to the CNAs and we try to incorporate it into daily stuff. When asked if they had received any instruction from Physical Therapy (PT) staff, the CAN stated We don't have PT. During an interview on 2/1/18 ay 6:00 pm, LN #2 stated Physical Therapy staff only came in to trim some of the residents toenails. On 1/31/18 at 4:40 pm, the survey team attempted to call the Physical Therapist with the phone number provided by the facility. Although a message was left there was no return call prior to exit on 2/2/18. . |
2020-09-01 |