| 5076 |
ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR |
115146 |
8414 WHITESVILLE ROAD |
COLUMBUS |
GA |
31907 |
2016-01-08 |
282 |
E |
1 |
0 |
UCIF11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, review of the Facility's Investigation Report and Facility staff Inservice Training Record review, the facility failed to ensure, for resident #30 was transferred with assistance of three staff assisting using the Mechanical Lift transfer as specified by the plan of care; for resident A, failed to obtain the Behavioral Health consult, failed to assess [MEDICAL TREATMENT] shunt site as specified by the plan of care, and: failed to notify the Physician of a cognitive change for one resident (#237), of the thirty-seven (37) sampled residents. Findings include: 1. For resident #30, the facility had identified a need for the resident to be transferred with the assistance of three (3) staff persons with a Mechanical Lift on the Transfer Assessment form which had initially been completed on 2/16/15. The assessment was based on the resident's physical condition, cognitive status and weight. The facility failed, however, to follow their plan of care, indicating the resident to be transferred with the assistance of three staff persons, to ensure the resident's safety during mechanical lift transfers. This failure resulted in a continued risk for subsequent falls during staff assisted transfers. Resident #30 had [DIAGNOSES REDACTED]. The resident had a plan of care of 1/29/15 for risk for falls/injury related to weakness, impaired mobility, cognitive loss, bilateral [MEDICAL CONDITION] since 2003, [MEDICAL CONDITION], balance deficit, incontinence, impaired vision and hearing, medication, and a history of falls. An intervention with the plan of care for this problem included to transfer the resident with appropriate devices, the use of the mechanical lift, and with three person assistance and to handle gently. An interview with certified nursing assistant (CNA) FF conducted on 1/7/16 at 4:30 p.m. revealed that she usually worked with this resident. CNA FF stated she worked with the resident on 12/22/15 at 6:00 a.m. CNA FF stated that she had just bathed the resident and called the charge nurse SS to help her to lift the resident from the bed to the wheelchair, using the mechanical lift. There was only CNA FF and Charge Nurse SS in the room to assist with the transfer. She further inaccurately stated that the resident required at least two staff person assistance with transfers for the mechanical lift and three staff assistance. The 1/7/16 written statement from CNA FF documented that while lowering the resident on to the reclining wheelchair, she discovered the resident was too far forward in the wheelchair, which began to tilt forward. Also, that she positioned herself behind the resident, with arms underneath the shoulders, while the Charge Nurse SS held the residents' legs and was unable to slide resident into proper position in wheelchair, the CNA FF and the Charge Nurse SS at that time slid the resident forward to the floor and slid the wheelchair out from underneath the resident. There was no injury to the resident. The facility failed to ensure that the plan of care for mechanical lift using three assistance was implemented on 12/22/15 when the resident was slid to the floor by CNA FF and charge nurse SS. Cross reference to F323. 2. Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Licensed nursing staff developed a plan of care on 9/16/15 that documented the resident was a new admission to the facility, had multiple medical problems, was alert and oriented and communicated without difficulty. A review of the clinical record revealed a 11/2/15 nurse's note entry that documented the resident complained of hearing and seeing things and of waking him/herself up at night by talking in his/her sleep. The plan of care was updated on 11/3/15 with a new intervention for a behavior consultation due to audio-visual hallucinations. After 11/3/15, although there was no evidence the resident continued to experience hallucinations, there was also no indication that licensed nursing staff had obtained the behavior consultation as care planned. During an interview on 1/8/16 at 12:25 p.m. the Assistant Director of Nursing (ADON) confirmed that the resident had not received the 11/3/15 behavior consultation to address hallucinations as care planned. Cross reference to F319. Licensed nursing staff developed a plan of care on 9/16/15 that documented that resident A was a [MEDICAL TREATMENT] patient and at risk for complications related to the shunt. The plan of care included interventions for licensed nursing staff to monitor the [MEDICAL TREATMENT] shunt every shift and following return from [MEDICAL TREATMENT] for bleeding and signs of infection; feel for thrill; auscultate bruit. Licensed nursing staff were to monitor the shunt dressing every shift to ensure the dressing was clean, dry and intact. However, a review of the clinical record revealed no evidence the [MEDICAL TREATMENT] shunt was being monitored as care planned. Licensed nurse PP stated on 1/7/16 at 1:35 p.m. that she worked with the resident infrequently but was aware the resident received [MEDICAL TREATMENT] and assessed the shunt site when returning from [MEDICAL TREATMENT]. Licensed nurse PP stated she had already checked the resident's shunt site on 1/7/16. Licensed nurse HH, who worked with the resident frequently, provided a statement on 1/8/16 at 9:54 a.m. documenting that she assessed the resident's [MEDICAL TREATMENT] shunt site after returning from [MEDICAL TREATMENT] treatments on Tuesdays, Thursdays and Saturdays. Resident A stated during an interview on 1/6/16 at 1:40 p.m. that the licensed nursing staff at the [MEDICAL TREATMENT] clinic assessed the shunt site on the days of [MEDICAL TREATMENT]. However, the resident stated licensed nursing staff at the facility did not assess the shunt site daily. However, there was no evidence in the medical record that the resident's [MEDICAL TREATMENT] shunt site was consistently monitored every shift, including on the days the resident did not receive [MEDICAL TREATMENT] as care planned. Cross reference to F309 3. Resident #237 had a 14 day MDS assessment with an Assessment Reference Date (ARD) of 9/27/15 completed by licensed nursing staff on 10/7/15. A quarterly MDS assessment with an ARD of 12/21/15 was completed on 12/23/15. A review of the MDS assessments revealed a decline in cognition from (MONTH) (YEAR) to (MONTH) (YEAR). The Brief Interview for Mental Status (BIMS) score declined from 12 to 5. Licensed nursing staff developed a plan of care, dated 9/30/15, that included the resident presented with memory recall deficit. The plan of care also included intervention to observe, document any changes in cognitive status, mood, behavior, sleep pattern, appetite, or infections and keep the Physician updated. However a review of the clinical record revealed no evidence that licensed nursing staff notified the Physician of the resident's decline in BIMS score from (MONTH) (YEAR) to (MONTH) (YEAR) as care planned. |
2019-01-01 |