| 5534 |
THE TERRACES OF PHOENIX |
35003 |
7550 NORTH 16TH STREET |
PHOENIX |
AZ |
85020 |
2013-03-13 |
323 |
E |
0 |
1 |
718011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that three residents received adequate supervision and assistance to prevent further accidents for three residents (#s 17, 152, and 117). The sample size was three. Findings include: Resident #17 was admitted to the facility on [DATE]. Review of the clinical records revealed a falls care plan dated November 14, 2012, due to impaired balance, impaired safety awareness, and one sided weakness. The interventions included to assure that assistive devices are placed appropriately in the room when not in use and to assure that the resident is able to use assistive devices correctly. Review of nurse's notes dated March 6, 2013, revealed that on March 6, 2013, at 10:00 a.m. the certified nursing assistant (CNA) reported that the resident was found on the floor laying next to her bed with her wheelchair at her feet. The resident did not have an alarm on her wheelchair at the time of the fall. Housekeeper who found her on the floor reported that no alarm was going off when she entered the room. An interview was conducted on March 14, 2013, with a licensed practical nurse (LPN). The LPN stated that when a resident has a fall they would be assessed, an incident report would be done, all the proper people would be notified. -Resident #152 was admitted to the facility on [DATE]. A review of the fall assessment dated [DATE], revealed a score of seven indicating that the resident was at a low risk for falls. A review of the minimum data set (MDS) dated [DATE], revealed documentation that the balance during transitions and walking is only able to stabilize with staff assistance. A review of the care plan revealed that fall risks had been initiated on March 12, 2012, and revised on March 12, 2012. A review of the clinical record lacked documented evidence that a fall assessment had been implemented following a fall on March 6, 2013, in which the resident sustained [REDACTED]. An interview with the director of nursing conducted on March 13, 2013, revealed that a fall assessment should have been completed following the fall. An interview conducted with the LPN on March 13, 2013, revealed that fall assessments are implemented immediately following a resident's fall. -Resident #117 was admitted to the facility October 26, 2012. A review of the Nursing Admission assessment dated [DATE], included that the resident's fall risk score was nine and at risk for falls. Progress Notes February 5, 2013, included that the resident had experienced a fall, and was found sitting on the floor mat at his bedside. Further review of the electronic Progress Notes dated February 17, 2013, and February 18, 2013, revealed that the resident had experienced another fall and was found laying on the floor next to his bed. A Weekly Progress Summary dated February 19, 2013, included that the resident had experienced a fall on February 17, 2013, and that the care plan had been reviewed and updated if needed. A review of the clinical record revealed no documented evidence that a fall risk assessment had been completed after the resident had two documented falls, and that a fall risk assessment had been conducted quarterly to identify factors that affected the resident's risk for falls. A review of the resident's care plan revealed that that a care plan was initiated October 26, 2012, and that the resident was identified as being at risk for or had a history of [REDACTED]. Interventions initiated November 11, 2012, included that a falls risk assessment would be completed quarterly and after each fall event, and that behaviors and factors that affected the risk for falls would be identified. During an interview conducted March 13, 2013, the director of nursing stated that a fall risk assessment had not been conducted after each fall, and quarterly, and that the care plan had not been updated. A review of the facility policy regarding falls revealed the following, .For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .After a first fall, a nurse will watch the resident attempt to rise from chair without using his arms, walk several paces and return to sitting and will document the results of this effort .Document appropriate interventions taken to prevent prevent future falls. Review of a facility policy titled Falls and Fall Risk, Managing, included that relevant interventions would be identified and implemented to try to minimize serious consequences of falling. |
2016-09-01 |