| 3462 |
ROCKDALE HEALTHCARE CENTER |
115670 |
1510 RENIASSANCE DRIVE |
CONYERS |
GA |
30012 |
2018-10-18 |
656 |
D |
1 |
1 |
WJ7611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of records and staff interview, it was determined that the facility failed to follow the plan of care related to activities of daily living (ADL) for two residents R#6 related to assistance with bed mobility and R#20 due to unkept nails, of 25 sampled residents. Findings include: Review of the clinical records for Resident (R) #20 revealed she was admitted on [DATE] and has current [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed the most recent assessment to be an Annual MDS assessment dated [DATE] revealed that R#20 was assessed as needing extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and total assistance with transfers. The resident was also assessed as needing the assistance of two plus people with bed mobility, transfers, and toilet use. Under the Care Area Assessment Summary of this assessment and the previous comprehensive MDS assessment of 8/14/17, ADLs triggered and the decision was made to complete a plan of care for that area. A review of the plan of care for R#20 revealed a plan of care in place since 8/28/17 for ADL/Self-care deficit revealed the resident needs two staff participation in toilet use, transfer, and bed mobility. A review of the facility incident report dated 5/11/18 and last revised 5/22/18 revealed that on 5/11/18 at 10:00 p.m., the charge nurse observed R#20 on the floor in her room with a Certified Nursing Assistant (CNA) at her side. The resident was assessed and assisted back to bed by two members of staff using the Hoyer lift. A review of the 200-hall assignment sheet of 5/11/18 revealed that CNA EE was assigned responsibility for caring for the residents in a block of rooms which included the room belonging to R#20. The assignment sheet also documented that a fall had occurred on CNA EE's shift. A review of an undated written statement by CNA EE revealed that she was in the room belonging to R#20 between 9:30 p.m. and 10:00 p.m. on the night of the incident, and was getting ready to change her. The CNA further reported that she went to the closet to get a brief, and while at the closet, she observed the resident's left leg sliding over the other. The CNA hurriedly went to the resident's assistance, but by the time she arrived at the bedside, the resident's legs were both over the side of the bed, the resident was holding on to the side rail which made it difficult for the CNA to return her legs to the bed. The CNA said she felt that the best thing to do at that point was to brace her fall because she was too heavy for me to help back on the bed. She used the bed sheet to help lower the resident to the floor before calling the nurse. Review of the facility's documented investigation of the incident, including a completed Continuous Quality Improvement form dated 5/14/18 revealed the facility determined that the CNA was providing care to the resident in the absence of other staff and the resident fell when the CNA left the resident unattended in bed while she went to the closet to retrieve a brief. The final determination was that the fall was a result of staff not following P[NAME] with bed mobility. The facility's proposed solution was ongoing education to staff including care plan training and Kardex system training beginning in orientation. An interview on 10/17/18 at 3:50 p.m. the with the Director of Nursing (DON) and the Assistant DON revealed the Continuous Quality Improvement (CQI) form is used after an incident to determine what were the contributing factors and what are the corrective actions to be taken. The CQI completed ,after this incident, documented what the facility felt contributed to the incident where R#20 sustained a fall and the actions they needed to take to avoid a repeat of the incident. In this case, it was determined that the CNA should not have been providing care to R#20 on her own and should have had at least two staff assisting the resident. It was also determined that the CNA needed to be educated related to how to determine the care needs of the residents. CNA EE was new at the time of the incident and it was determined that the first step in education should be limited to her. However, it was also determined that other staff would later receive reeducation on accessing information related to the needs of residents in their care. The CNA was no longer employed at the facility. A review of the facility records revealed documentation that CNA EE received education from the ADON on 5/14/18 related to: the importance of checking to see what level of assistance (1 or 2 staff) each resident required; the importance of following the plan of care to ensure safety during resident care; and the importance of not positioning a resident and leaving that resident to gather more supplies. 2. Review of clinical record for R#6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 00, which indicated severe cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of the care plan initiated on 4/10/18 and revised on 10/12/18, revealed resident has Activities of Daily Living (ADL) self care performance deficit related to [MEDICAL CONDITIONS] with right arm weakness, right elbow contracture and left leg weakness. Interventions to care include resident requires total dependence for personal care hygiene. Observation on 10/16/18 at 11:07 a.m., 10/17/18 at 9:26 a.m. and 10/18/18 at 10:48 a.m. revealed resident with long nails with brown substance underneath them on both hands. Interview on 10/17/18 at 9:37 a.m., with Certified Nursing Assistant (CNA) GG stated that for ADL care, she bathes residents on their bath days, she gets them up, dresses them, brushes their teeth, brushes hair, shaves residents if they need it and also stated that she does nail care on bath days, unless they need it more often. She stated that she did not notice R#6 with dirty fingernails today. Interview on 10/18/18 at 10:10 a.m. Licensed Practical Nurse (LPN) Unit Manager HH, stated her expectation is staff provide care as per orders and/or care plan. ADL care consists of nail care and should be done on bath days, but can be and should be done more often, if needed. She further stated she encourages charge nurses to assist CNA's with persuading residents to accept care. Verified R#6 nails were long and dirty with brown material underneath. Interview on 10/18/18 at 3:05 p.m., with Director of Nursing (DON), stated it is her expectation that staff follow the care plan as written pertaining to all aspects of care, including nail care. She further stated that if the CNA's need help with ADL care, they should be getting help from their Charge Nurse and their Unit Manager. DON stated the facility did not have a policy for nail care. Cross refer F677 |
2020-09-01 |