| 44 |
PLANTATION MANOR NURSING HOME |
15015 |
6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 |
MC CALLA |
AL |
35111 |
2018-04-19 |
842 |
D |
0 |
1 |
K9LV11 |
Based on medical record review, interviews, and a review of a facility policy titled, Incident and Accident Report, the facility failed to ensure an incident/accident report regarding a fall RI (Resident Identifier) #45 sustained on 2/14/18 was done. This affected RI #45, one of two residents sampled for falls. Findings Include: A review of an undated facility policy titled, Incident and Accident Report, revealed: Purpose: Incident and accident reports are filled out to study the cause of an accident or incident and to take corrective action. Policy: The incident and accident form is to be filled out immediately by LPN (Licensed Practical Nurse) Charge Nurse, department head or supervisor when notified of an injury or accident. Procedure: [NAME] If an incident or accident occurs: . 4. If the incident involved a resident, chart the information required including: Sponsor (who and when Notified) Time the physician was notified Resident vital signs . During the review of the fall reports, the surveyor was made aware by the facility RI #45 had a fall on 2/14/18. A review of RI #45's medical record revealed no incident/accident report for the fall sustained on 2/14/18. An interview was conducted with EI (Employee Identifier) #6, a LPN (Licensed Practical Nurse), on 4/19/18 at 3:33 PM. EI #6 was asked who was responsible for documenting resident information in the medical record and she answered, The Nurse. EI #6 was asked who should have documented the fall RI #45 had on 2/14/18. EI #6 answered, The Nurse that responded. EI #6 was asked who was the nurse that responded and she answered, Me, I was the Nurse. EI #6 was asked why was this not done. EI #6 answered, I had started it and had a medical emergency and had to leave the facility. EI #6 was asked what she documented prior to leaving. EI #6 answered she had documented everything except for the notification part and she had not gotten the witness statement. EI #6 was asked where was that documentation. EI #6 answered, We think it must have gotten lost. EI #6 was asked where she last saw the incident form. EI #6 answered, In the med room on East wing on the desk. EI #6 was asked what was the facility's policy regarding complete and accurate documentation in the medical record and she answered, For it to be done and correctly. EI #6 was asked what was the concern of documentation not being entered into the medical record. EI #6 answered, Patient safety because we need to know. EI #6 was asked who was responsible for ensuring documentation was completed and accurate and she answered everyone that documented. An interview was conducted with EI #5, the DON (Director of Nursing), on 4/19/18 at 3:46 PM. EI #5 was asked who was responsible for documenting resident information in the medical record and she answered, The Charge Nurses. EI #5 was asked who should have documented the fall RI #45 had on 2/14/18. EI #5 answered, The Charge Nurse. EI #5 was asked who was the Charge Nurse and she answered EI #6. EI #5 was asked why this was not done and she answered, I don't know. EI #5 was asked what was the facility's policy regarding completed and accurate documentation in the medical record. EI #5 answered, That it should be done and accurate. EI #5 was asked what was the concern of documentation not entered into the medical record. EI #5 answered, That something may have happened that no one is aware of. EI #5 was asked who conduced fall investigations and she answered, The Charge Nurse initiates including witness statements and the restorative nurse initiates interventions. EI #5 was asked if was done for RI #45's fall and she answered yes, but it was not documented. EI #6 was asked how can verification be obtained that a fall was investigated if there was no documentation. EI #5 repeated there was no documentation. EI #5 was asked who was responsible for ensuring documentation was completed and accurate. EI #5 stated she was responsible. |
2020-09-01 |