| 32 |
PARKVIEW NURSING |
85002 |
2801 W. 6TH STREET |
WILMINGTON |
DE |
19805 |
2017-05-03 |
280 |
D |
0 |
1 |
ZLDY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that for one (R27) out of 27 Stage 2 sampled residents, the care plan was revised by a team of qualified persons after each of R27's fall assessments. Findings include: The facility's policy entitled, Fall Management dated 3/16/16 included: Develop a plan of care which can include general and specific interventions to reduce falls risk .Implement intervention (immediate) after the fall. As the investigation continues the root cause analysis may trigger additional interventions to resident plan of care .Update the care plan and CNA communication form with new intervention. Review of R27's clinical record revealed the following: R27 was originally admitted to the facility on [DATE] 07/17/15-The facility originally initiated a care plan that stated, Actual/Potential for falls r/t poor safety awareness, cognitive impairment. The initial approaches included: Resident to wear shoes when out of bed, double sided non skid socks while in bed PT/OT eval and assessment PRN Keep call bell within reach as resident allows Have commonly used articles within easy reach Ensure environment is free of clutter 8/28/15 - updated with offer frequent rest period 9/26/16 - updated with Toileting program 12/6/16 - Fall Risk assessment stated that R27 was a high risk for falls. 1/7/17 - Fall Risk assessment identified R27 was a high risk for falls and had a balance problem while walking A review of R27's Nursing Progress notes revealed the following: 1/7/2017 at 13:24 (1:24 PM)-A nursing progress note stated that the resident was found sitting on the floor on her buttocks in the hallway, holding her bleeding mouth. R27 sustained laceration to exterior lower lip and internal lower lip that required hospitalization . R27's bottom lip required sutures when hospitalized . There was no documentation in the care plan that it was updated/revised to reflect immediate intervention implementation after the fall to prevent re-occurrence. 1/9/17- (2 days later), The facility's post fall Verification of Investigation Report for the 1/7/17 fall, identified the following 2 triggered modified interventions to the plan of care: :1) Psychiatrist's review; 2)Therapy referral ( already part of the initial approaches since 7/17/15). The facility failed to update/revise the existing care plan to include a Psychiatrist review. In addition, on 1-9-17- 1/30/17,R27 was under PT's services. PT's evaluation and treatment services summary stated that Nursing was educated to supervise R27 to reduce risk of falls. The facility failed to update/revise the existing care plan to include the type of supervision that was put in place. 1/31/17 - Nursing Progress note stated that R27 at 1:25 AM was out of bed ambulating in the dayroom, lost her balance, fell to the floor hitting her head on the wall. R27 sustained bleeding from the back of her head and was sent to the hospital emergency room for evaluation and treatment. R27 returned to the facility with 3 staples on her posterior scalp laceration. 1/31/17 -The facility's after fall Verification of Investigation identified the following modified interventions to the plan of care: 1) therapy trialed on wheelchair; 2) Anti roll back to wheelchair and dycem initiated; 3) 1 person assist for all transfers and ambulation; 4) every 30 minute safety check; 5) continue offering rest periods. The facility failed to revise/update the care plan to include, the every 30 minute safety check according to the facility's modified interventions identified on 1/31/17 Verification of Investigation. 2/01/17 - R27's Fall care plan was updated/revised and included hip protectors on at all times; 2/3/17-R27's Fall care plan was edited/revised and included the intervention that R27 requires one person assist for safe transfers and ambulation and dycem to wheelchair, wheelchair with anti-roll backs; 2/3/17 -The facility identified that they will request ambulation program. The facility failed to revise the care plan to include this intervention after the 1/31/17 fall. 2/7/17 - The facility identified a nursing intervention to move R27 closer to nursing station. However, the facility failed to revise the care plan to reflect this intervention. 2/16/17- The facility identified a nursing intervention that the Resident was tried with Rolling Walker- not successful. The facility failed to revise the care plan to include this intervention. 2/17/17 -Nursing Progress note stated that R27 was on restorative ambulation program, nursing staff offer hand held assist with ambulation as able. The facility failed to revise/update the care plan for 2/17/17 to include the intervention, Restorative ambulation program. 3/30/17 at 2:57 PM- Nursing Progress note stated that a Rehabilitation staff E7 (OT) was walking towards the linen closet and observed resident ambulating towards main dining room entrance and tripped over fell ow residents wheel of wheelchair and that resident softly hit the back of her head against the corner of entrance of the main dining room and slowly slid to floor. R27 did not sustain injury. 3/31/17-The Verification of Investigation Report for the 3/30/17 fall identified the Modified interventions to the plan of care that stated offered helmet -refused by family. The facility failed to revise the care plan to include the intervention, offered helmet-refused by family. There was no evidence that the facility updated/revised the Fall care plan to address R27's actual falls after the incidents on 1/7/17, 1/31/17, and 3/31/17. 4/3/17- Nurse's note stated that E8 (LPN) heard a thud on the hallway and saw resident on the floor. On assessment R27 sustained hematoma on her occiput area, patient verbalized pain on palpation and was sent to hospital ER for evaluation and treatment. 4/4/17-The intervention Redirect resident to common areas as able was added in response to the 4/3/17 incident of fall. Although the facility periodically reviewed the care plan, it failed to update/revise R27's Fall care plan to include the immediate and specific modified interventions identified in their incident investigations after each fall, including the triggered additional intervention as the investigation continued. 4/11/17-R27 had an unwitnessed fall in her room and sustained Periorbital and facial trauma + lips, hematoma on right shoulder, left and right forearm, left elbow, right knee, left lower extremity and was transported to the hospital for evaluation and treatment. On 4/11/17 and 4/13/17, it was then that the facility revised R27's care plan and put in place the general and specific interventions to reduce falls risk, implemented intervention (immediate) after the fall such as the Bed sensor alarm, Check placement and function every shift, Egress mattress, keep room well lit and clutter free, keep overhead light on while resident in bed, low bed, fall mat at bedside, mobility alarm to rock and go chair and rock and go chair plus restorative ambulation program. This finding was reviewed with E2 (NHA) and E2 (DON) on 5/2/17 at 1:45 PM. |
2020-09-01 |