cms_DC: 13
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 13 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 689 | G | 0 | 1 | BMNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure one (1) resident who was identified as a fall risk received adequate supervision. The resident was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 Findings included . A review of the Resident's Clinical record showed that on (MONTH) 7, 2019, at 11: 00 AM Resident #182 was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A review of Resident #182's admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 11 which indicates the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with one (1) person physical assist for bed mobility, transfer, locomotion on the unit and locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as1 to indicate that the resident had a fall 2 - 6 months prior to his admission to the facility. A review of the care plan initiated on 5/17/19 showed resident at risk for falling r/t (related) cognitive impairment, unsteady gait and [DIAGNOSES REDACTED]. resident was observe on the floor with no injury. There was no mention that Resident #182 had a fall on 7/7/19. A review of the Resident's progress note showed the following: 7/7/19/ 1:41 PM Writer (RN Supervisor) was called to unit 3 green and noted resident in a sitting position in front of his wheel chair in the solarium. Upon assessment resident denied pain or discomfort, no injury noted, denied hitting his head able to move his upper arm and lower extremities without difficulty to his baseline. Resident was asked how he got to the floor he said that he did not know 7/9/19 1:51 PM NP's (Nurse Practitioner's) Progress note showed Pt c/o pain today at left leg . x-ray ordered . pain with ROM at left leg at knee part, had pain earlier at left hip, slight swelling left leg and lower thigh, x-ray left leg. 7/10/19 9:52 AM (RN) late entry for 7/9/19 Resident is status [REDACTED]. Seen by the NP .due to complaint of pain on the left hip that radiates to the lower extremity. As result, x-ray of the left hip, left femur and left knee was ordered. X-ray was done at 3 pm, preliminary x-ray result showed resident has [MEDICAL CONDITION] femur NP was notified An order to transfer resident to the emergency room . A review of the result of the stat x-ray of left femur, left knee, left hip and pelvis on 7/9/19 ordered by NP showed Impression: Acute [MEDICAL CONDITION] Left Femur. A face to face interview was conducted on 7/26/19 at 1:55 PM with Employee #19 (CNA) who stated, I was in the solarium watching and monitoring residents when my coworker in the room next to the solarium asked me for help to put a resident in chair. I left the solarium to the room right outside the solarium to help with another resident. While in the room I heard someone say resident on the floor in solarium and ran back in there he was sitting on the floor in front of wheel chair. On Tuesday I was giving AM care when I went to move him he says ouch, ouch. I asked what was wrong he pointed to left side of hip. I called charge nurse and she came to see him. Another face to face interview was conducted on 7/26/19 at 1:59 PM with Employee #20 (CNA) who stated, I was in (resident,s name) room getting her ready to get out of bed, (CNA name) in solarium covering residents in solarium. I had went to her to ask her to help me put (resident's name) in chair. She did and while in room another resident called out patient on floor. We both ran out to solarium he was sitting up on the floor beside his wheel chair. He did not complain staff came and assessed him. The evidence showed that facility staff failed to ensure one (1) resident who sustained a fall with an injury received adequate supervision to prevent an accident as evidenced by the staff assigned to watch and monitor the residents in the solarium left him unattended. During a face-to-face interview with Employee #13 (unit manager) on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone. | 2020-09-01 |