| 58 |
ATHENS HEALTH AND REHABILITATION LLC |
15016 |
611 WEST MARKET STREET |
ATHENS |
AL |
35611 |
2019-12-19 |
656 |
D |
1 |
0 |
QVJE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, a review of RI (Resident Identifier) #1's medical record, RI #1's Resident Incident Report, and the facility's policy titled, Person Centered Care Plans, the facility failed to ensure RI #1's care plan for a fall mat beside the bed was consistently implemented. This deficient practice affected RI #1, one of three sampled residents reviewed for falls. Findings Include: A review of a facility policy titled, Person Centered Care Plans, with an effective date of 8/15/18, documented: PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights. STANDARD: . According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . PR[NAME]ESS: I.(f) .will ensure care plan intervention(s) are entered into Care Guide ADLs/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/19, indicated RI #1 was cognitively intact, with a BIMS(Brief Interview for Mental Status) score of 14. RI #1's Resident Incident Report, prepared by EI (Employee Identifier) #1, RN (Registered Nurse), DON (Director of Nursing Services), indicated on 11/30/19 at 8:35 p.m., CNAs (Certified Nursing Assistants) EI #2 and E#3 called the nurse to the resident's room. The resident was lying on his/her left side, on the floor, beside the bed. RI #1's care plan titled, Potential for Falls: r/t (related to) bilateral AKA, lists the following interventions: Mat beside bed, with a start date of 9/10/19. On 12/11/19 at 9:30 a.m., an interview was conducted with EI #4, a CN[NAME] EI #4 was asked to tell the surveyor about the incident that happened on 11/30/19 involving RI #1. EI #4 said she was coming out of another resident's room and heard RI #1 hollering for help. EI #4 was asked what happened after hearing the resident. EI #4 said she, EI #2 and EI #3 all entered RI #1's room about the same time. EI #4 was asked what she saw when she entered the resident's room. EI #4 said RI #1 was on the floor. The resident told them he/she rolled over and fell . EI #4 was asked if she saw the fall mat in the room. EI #4 said no, after the fact she saw it in the closet because the closet door was open. EI #4 was asked if RI #1 was care planned for a fall mat. EI #4 said yes, it was on the care plan. On 12/11/19 at 12:31 p.m., an interview was conducted with EI #2, CN[NAME] EI #2 was asked if she found RI #1 on the floor on 11/30/19 at about 8:30 p.m. EI #2 said yes. EI #2 was asked what she saw when she entered RI #1's room. EI #2 said the resident was lying on his/her left side, on the floor facing the television. EI #2 was asked how she knew the resident was on the floor. EI # 2 said she heard the resident screaming for help. EI #2 was asked if she was the first person to enter the room. EI #2 said she and EI #3 entered the room at the same time. EI #2 was asked did she or EI #3 put RI #1's fall mat by RI #1's bed. EI #2 said no. EI #2 was asked who was responsible for putting the mat on the floor bedside. EI #2 said EI #3 and she were both responsible. EI #2 was asked was the care plan followed if the fall mat was not on the floor, bedside. EI #2 said no. On 12/11/19 at 3:15 p.m., an interview was conducted with EI #3, a CN[NAME] EI #3 was asked if he was assigned to care for RI #1 on 11/30/19 when the resident fell . EI #3 said he, EI #2 and EI #4, another CNA, were doing rooms together. EI #3 was asked where RI #1 was prior to the fall. EI #3 said the resident was in the wheelchair and he and EI #2 put the resident in the bed. EI #3 was asked if he or EI #2 put the fall mat on the floor by RI #1's bed. EI #3 said no, he did not put the fall mat on the floor. EI #3 was asked if he saw EI #2 put the fall mat on the floor. EI #3 said he did not know about the fall mat and when he was in the room he did not see a fall mat. EI #5 told him the resident needed to have the fall mat, after the fact, and pointed out that the fall mat was in the closet. EI #3 was asked if he saw the fall mat in the closet. EI #3 said yes, EI #5 pointed it out to him and he saw it in the closet. On 12/12/19 at 2:39 p.m., an interview was conducted with EI #1, Registered Nurse/ Director of Nursing. EI #1 was asked what the facility determined was the cause of the fall after the investigation. EI #1 said RI #1 was rolling himself/herself over to the left side and the resident kept rolling and hit the floor. EI #1 was asked if all of RI #1's interventions were in place when the resident had the fall. EI #1 said no, the mat was not in place. EI #1 was asked if the facility determined why the mat was not on the floor. EI #1 said the staff reported it was in the closet. EI #1 was asked if the staff followed the care plan. EI #1 said no, they did not. EI #1 was asked if the staff should have followed the care plan. EI #1 said yes. EI #1 was asked what the facility did to correct the problem. EI #1 said they had an emergency QA (Quality Assurance) meeting on 12/4/19 to put a plan in place. Education began on 12/1/19 to all staff about fall prevention and following interventions on care plans. The care plans for all residents at risk for falls were reviewed and updated. On 12/2/19 all care guides were reviewed for interventions. The RN Managers on each unit audited fall care plans and began monitoring them weekly. As the result of the staff not following RI #1's care plan intervention for a fall mat at bedside, the facility implemented the following action plan to ensure this deficient practice does not reoccur. 1. DON/Designee provided 1:1 in-service with the 2 CNAs on 12/1/2019 that failed to ensure RI #1's care plan intervention of a fall mat at bedside was implemented regarding fall prevention and following care plans. 2. DON/Designee will complete an audit of current active residents to ensure that current resident's care planned for fall mats are updated and implemented. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. The audit was completed by 12/2/19. 3. ADON (Assistant Director of Nursing)/Designee will in-service all nursing staff to ensure they are following and implementing residents care plans. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. These in-services were completed by 12/4/19. 4. DON/Designee will monitor residents' care plans that include fall mats 2 days a week x 4 weeks, then monthly thereafter for 3 months to ensure residents' care planed for fall mats are being utilized. Any concerns noted will be addressed/corrected, additional education will be provided and monitoring will continue. A copy of these checks will be kept in a binder in the Administrator's office. |
2020-09-01 |