cms_GA: 10495
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10495 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2010-09-23 | 280 | K | 1 | 0 | KDKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to appropriately review and revise care plans to ensure the ongoing development of effective interventions and approaches to provide adequate supervision related to repeated falls for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck their heads a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to reassess and reevaluate these residents and their Plans of Care appropriately to develop interventions and approaches to minimize falls had resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurrence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of the appropriate interventions. However, during an interview conducted with Nurse "EE" on 09/02/2010 at 9:30 a.m., this nurse acknowledged that the facility did not reevaluate residents for falls. During an interview conducted with Nurse "EE" on 09/02/2010 at 11:10 a.m., this nurse stated that high risk fall assessments were not being completed periodically on residents, and that resident Care Plans were not being revised to reflect new interventions to prevent falls. During an additional interview with Nurse "EE" conducted on 09/23/2010 at 1:00 p.m., this nurse stated that the facility did initial assessments on residents at the time of admission to determine the fall risk, but reiterated that the facility did not reevaluate residents for falls. During an interview conducted with the Director of Nursing on 08/30/2010 at 3:30 p.m., the Director of Nursing acknowledged that residents had not been adequately assessed for falls. 1. Cross refer to F323, example 1. Record review for Resident #2 revealed an MDS assessment of 01/11/2010 documented that the resident's date of admission was 12/30/2009, and documented [DIAGNOSES REDACTED]. The Resident Care Plan for Resident #2 reference a 01/11/2010 entry which identified falls as a problem both prior to admission and since admission secondary to unsteady gait/balance, the resident's behavior of transferring unassisted at times, and [MEDICAL CONDITION]. Approaches to address this resident's fall risk included the use of a personal protection alarm at all times and to monitor and report any attempts to transfer/ambulate unassisted. Record review revealed Incident Reports of 03/30/2010 at 12:45 p.m., 04/03/2010 at 4:00 p.m., 04/07/2010 at 5:40 a.m., 04/30/2010 at 7:00 p.m., 06/05/2010 at 7:00 p.m., 06/22/2010 at 2:00 p.m., 06/25/2010 at 11:50 a.m., and 08/13/2010 at 4:30 p.m. which documented that Resident #2 had experienced falls. Additionally, a 04/28/2010 Incident Report timed at 5:00 a.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall while getting out of bed, and was assessed to have a small amount of bleeding from the left nostril was noted, and a 1 inch in diameter raised area was noted on the resident's left frontal hairline. The resident's left cheek and eye were red and swollen, with an eyeball hemorrhage noted in the outer aspect of the eye, and the right knee was red with an abrasion. Also, a Nurse's Note dated 07/16/2010 at 7:45 a.m. documented that Resident #2 had an unwitnessed fall on 07/15/2010 at 7:50 p.m., and that the resident stated she had bumped her head. Based on the above, the facility had identified Resident # 2 to be at risk for falls, with a 01/11/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk, which included the use of a personal protection alarm at all times. However, the resident experienced ten (10) subsequent falls between 03/30/2010 and 08/13/2010 from the bed, the wheelchair, or while ambulating, with the 04/28/2010 fall resulting in the resident striking the head, causing a raised area on the hairline, left cheek and eye swelling, and an eye ball hemorrhage. Review of the Resident Care Plan revealed an updated entry of 03/16/2010 indicating the resident was on the wheelchair positioning program. However, the specific falls of 04/30/2010 and 06/25/2010 occurred while the resident was in the wheelchair, after the initiation of this 03/16/2010 intervention. But, further record review, to include review of the Resident Care Plan, revealed no evidence to indicate that the facility had reassessed and revaluated the resident to identify additional interventions and approaches to address the resident's continued falls from the wheelchair, or to identify additional interventions to address the resident's continued falls from the bed and while ambulating. Based on the above, the facility failed to appropriately reassess and reevaluate Resident #2, who received [MEDICATION NAME] anticoagulant drug therapy, to develop effective interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident from continuing to sustain falls, including one fall which resulted in injury. 2. Cross refer to F323, example 2. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment of 09/09/2009 which documented that the resident had been admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The resident's Resident Care Plan contained an entry, originally dated 09/09/2009, which identified that the resident was at risk for falls related to a history of falls and a cognitive deficit. This Care Plan identified multiple Approaches to address this resident's risk for falls, including to provide the limited assistance of one person with ambulation and transfers, to monitor the resident's gait and to provide more assistance as needed. Care Plan Approaches also included the use of a bed alarm to alert staff of any attempts of the resident to rise from bed without assistance, although a 02/05/2010, 9:30 a.m. Nurse's Notes Quarterly Review indicated that the resident had utilized a bed alarm in the past, but that it had been discontinued at that time. Record review revealed Nurse's Notes and/or Incident reports of 03/09/2010 at 1:50 a.m., 03/30/2010 at 2:30 p.m., 04/07/2010 at 6:15 p.m., 05/08/2010 at 3:30 a.m., 05/25/2010 at 4:25 p.m., 06/14/2010 at 2:10 p.m., 06/29/2010 at 9:00 p.m., and 07/01/2010 at 9:30 a.m. which documented that Resident #1 had experienced falls. Additionally, Resident #1 experienced the following falls during which she struck her head resulting in redness or injury: A Nurse's Note of 04/14/2010 at 8:30 p.m. documented that the resident was sitting in the common area in a recliner, fallen to the floor, and was assessed to have a reddened area on the left forehead. A Nurse's Note of 04/19/2010 at 6:30 p.m. documented that the resident was on the floor in the bathroom and was noted to have a reddened area on the posterior scalp. A Nurse's Note of 05/21/2010 at 3:30 p.m. documented that staff had found the resident on the floor in the bathroom, having bumped her head on the floor causing a hematoma. A Nurse's Note of 06/14/2010 at 2:10 p.m. documented that the resident was found on the floor between the doorway of another resident's room in the hallway, having slight redness to the head upon assessment. Record review revealed that the facility, as one specific intervention, had initiated via a physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that, after having initially assessed the resident to be at risk for falls and devising Approaches on the 09/09/2009 Resident Care Plan to address this risk, the facility had reevaluated the resident to develop additional interventions related to the eleven (11) subsequent falls the resident sustained [REDACTED]. And, specifically during the falls of 03/30/2010, 04/14/2010, 04/19/2010, 05/21/2010, and 06/14/2010, the resident hit her head, requiring the initiation of neurological checks, with the fall of 05/21/2010 also resulting in a hematoma. Based on the above, the facility failed to adequately reassess and reevaluate Resident #1, who received aspirin anticoagulant drug therapy, to develop effective approaches and interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, including falls resulting in injury. 3. Cross refer to F323, example 3. Record review for Resident #7 revealed an MDS of 03/26/2010 which documented a date of entry to the facility of 03/16/2010, and which documented that the resident had [DIAGNOSES REDACTED]. The Resident Care Plan for Resident #7 identified a problem, with an original date of 03/25/2010, of the resident being at risk for falls related to a history of falls, poor cognition, muscle weakness, and an unsteady gait. This Care Plan included, as Approaches to address the resident's risk for falls, for staff to assist the resident with ambulation as needed and tolerated, and for a bed alarm to be used while in bed. Record review revealed Incident Reports dated 03/26/2010 at 6:00 p.m., 03/27/2010 at 4:00 p.m., 03/30/2010 at 10:30 a.m., 03/30/2010 at 4:45 p.m., 04/10/2010 at 9:00 a.m., 04/12/2010 at 08:30 a.m., 04/18/2010 at 4:00 a.m., 06/04/2010 at 2:10 p.m., 07/11/2010 at 7:00 a.m., 07/13/2010 at 1:00 p.m., 07/26/2010 at 5:15 a.m., and 08/22/2010 at 10:50 a.m. which documented that Resident #7 had experienced falls. Additionally, Resident #7 had experienced the following falls resulting in the resident striking her head and/or sustaining injury: An Incident Report dated 04/07/2010 at 2:00 p.m. documented that the resident had fallen while ambulating ad lib in the common area and had sustained a five-and-one-half (5 1/2) cm. by four (4) cm. hematoma to the posterior head. An Incident Report dated 05/16/2010 at 2:15 p.m. documented that the resident had experienced an unwitnessed fall in the resident's room, and a red/purple area on the lower back of the resident's right hip was noted. An Incident Report of 05/31/2010 at 7:20 a.m. documented that the resident had experienced an unwitnessed fall and had sustained a skin tear to the right elbow. An Incident Report of 06/18/2010 at 7:20 a.m. documented that the resident had experienced an unwitnessed fall, was observed with her head propped against the bed stand, and was noted with a hematoma on top of the head. An Incident Report of 07/21/2010 at 7:45 p.m. documented that the resident fell between the chair and couch, and sustained a one (1) inch laceration to the right brow. The facility had identified Resident #7, who received aspirin anticoagulant drug therapy, to be at risk for falls, with a 03/25/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk. However, the resident experienced fourteen (14) subsequent falls between 03/26/2010 and 08/22/2010 from the recliner or while ambulating, with the resident hitting her head during the specific falls of 04/07/2010, 04/15/2010, and 07/21/2010, sustaining a hematoma to the head during the fall of 04/07/2010 and a laceration to the head during the fall of 07/21/2010. There was, however, no evidence to indicate that the facility reevaluated the resident for continued falls from the recliner and while ambulating after the initial assessment of 03/25/2010. Additionally, the resident experienced a fall from the bed on 04/18/2010, resulting in the addition of a low rise bed on 04/27/2010 and the discontinuation of the use of the bed alarm on 05/07/2010, as documented in entries to the Resident Care Plan. The resident then experienced another fall from the bed on 05/16/2010, but there was no evidence to indicate that the facility reassessed and reevaluated the resident after this fall from the bed to identify interventions to prevent further falls, and the resident thus sustained two (2) subsequent falls from the bed, on 05/31/2010 and 06/18/2010, with the resident hitting her head and sustaining a hematoma to the head during the fall of 06/18/2010. Based on the above, the facility failed to reassess and reevaluate Resident #7, who received aspirin anticoagulant drug therapy, to develop effective interventions to address the resident's continued falls. The facility thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, including falls resulting in injury. 4. Cross refer to F323, example 4. Record review for Resident #8 revealed an Admission MDS of 12/30/2008 which documented the resident had been admitted to the facility on [DATE]. The Resident Care Plan for Resident #8 identified, as an entry originally dated 09/28/2009, that the resident was at risk for falls related to cognitive deficit and an unsteady gait, with Approaches which included the use of a wheelchair for locomotion, responding promptly, and keeping the call light within easy reach, even though this Care Plan also noted that the resident's cognition might be such that she could not use the call light. This Care Plan referenced additional Approaches, also dating from 09/28/2009, specifying the application of a bed alarm to the bed and the application of a patient protector alarm while out of bed, but a notation on the Care Plan documented that these Approaches had been discontinued on 02/15/2010. The Care Plan for falls also referenced an entry dated 05/31/2010 which specified the use of a left half-rail for bed mobility. Record review revealed Incident Reports dated 07/17/2010 at 10:05 p.m., 07/22/2010 at 5:35 p.m., 08/04/2010 at 2:45 a.m., and 08/08/2010 at 1:30 a.m. which documented that Resident #8 had sustained falls. The facility had identified Resident #8 to be at risk for falls, with a 09/28/2009 Resident Care Plan entry identifying this risk and Approaches to address the risk, two of which were the use of bed and patient protector alarms which were then discontinued on 02/15/2010. The facility then implemented, per the Care Plan, the use of a half-rail in the bed as an additional intervention to address falls on 05/31/2010. However, the resident then experienced four (4) subsequent falls between 07/17/2010 and 08/08/2010, with a fall of 07/22/2010 being from the wheelchair and a fall of 08/08/2010 being from bed, but there was no evidence to indicate that the facility had reevaluated the resident for these continued falls to develop interventions and approaches to prevent further falls. Based on the above, the facility failed to appropriately develop effective interventions to address Resident #8's continued falls, including falls from the bed and wheelchair, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls. It was determined that the immediate jeopardy was removed as of September 23, 2010, at which time the facility had completed the following actions: - On 08/31/2010, policy revisions were made for Head Injury, and licensed staff members were inserviced by the Director of Nursing. - On 09/08/2010, policy revisions were made for Fall Risk Precautions, and were reviewed by the Director of Nursing presented to staff members via inservice training. - On 09/13/2010, a policy was put into place requiring that all new incidents be reviewed in the morning clinical staff meeting by the Interdisciplinary Team to ensure that interventions were put into place, and that Care Plans and ADL's were updated with new interventions. This process was inserviced and monitored by the United Clinical Consultant during the first week of implementation. The Director of Nursing was then be responsible for the conducting of the morning clinical meeting as of 09/22/10. - On 09/14/2010, the incident Occurrence Reduction Program was implemented. Then, on 09/21/2010, inservice was provided to licensed nursing staff regarding the Occurrence Reduction program. - On 09/14/2010, a 100 % review of all incidents that had occurred in the facility for the past 60 days was completed by United Clinical Services Consultants to assess interventions and follow-up, and to determine if residents met the criteria for the Occurrence Reduction program. Four (4) residents met the criteria to be placed on the occurrence reduction program. - On 09/17/2010, remaining residents had been assessed and determined to have appropriate interventions and Care Plans, and ADL Records were updated to reflect interventions. - On 09/22/2010, a schedule was implemented, per the Occurrence Reduction program, to ensure that each resident has a fall risk assessment each, and licensed nursing staff were inserviced on completing occurrence reports, implementing interventions, updating Care Plans, and ADL records. - The facility will review all findings of assessments and the progress of the newly implemented policies and procedures in the next Quality Assurance Meeting scheduled on Friday, September 24, 2010. - Newly employed nurses will be educated, upon hire, regarding the Occurrence Reduction program, falls assessments, completing incident reports, updating care plans, ADL records and assessment for residents change in condition. Based on the corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on September 23, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted inservice training to many licensed nursing staff members regarding the Occurrence Reduction Program as of 09/22/2010, but six (6) nursing staff received this inservice training on 09/23/2010, the last day of this complaint survey. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems with both existing and new staff. Additionally, the facility is to have weekly Occurrence Reduction Program meetings to discuss residents determined to meet criteria for inclusion into the Program, but the first weekly meeting was not held until 09/23/2010, the last day of this survey. Also, the progress of the newly implemented policies and procedures is to be monitored through the facility's Quality Assurance program, but the next Quality Assurance Meeting was not scheduled to occur until Friday, 09/24/2010, the day after the completion of this complaint survey. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "E" level. | 2014-07-01 |