cms_GU: 59
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 59 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2013-09-20 | 274 | D | 0 | 1 | JK1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to conduct a comprehensive assessment of Resident 5 after there was a significant change in the resident's medical/mental condition. Resident 5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident 'might want to hurt or kill' themselves. During the tour, the resident was not observed to be in their assigned resident room. Throughout the morning and early afternoon of (MONTH) 18, the resident was observed to be self-propelling herself throughout the facility and outside to the patio located at the front entrance of the facility. An interview with Resident 5 at approximately 1:30 PM on (MONTH) 18, 2013 was done, and they indicated they would be going to an off-campus appointment at 2:30 PM for the remainder of the afternoon. The resident said they felt okay ', and enjoyed going outdoors for fresh air. When asked about their mood, they indicated that they had recently been moved to another room, because a friend called the facility and reported that they (the resident) was trying to cut and kill myself with a knife. She added that it was 'a misunderstanding', and that she was okay now. An interview was done with LN 3 on (MONTH) 19, 2013 at approximately 5:10 PM. The staff person stated that they were not the assigned staff for the resident that shift, and that toward the end of the shift (3 PM - 11 PM) they took a phone call from the friend of the resident on (MONTH) 13, 2013. LN 3 said the caller sounded worried and like they were about to cry, and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad. LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 said that she heard the staff say that the door was locked, and responded to other staff that the door can't be locked because there is no lock on the doors. Staff 3 said that staff then thought that the resident might have barricaded the door closed. Staff 3 said the door was finally opened and they checked on the resident. Staff 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. The staff person added that security was informed to watch her just in case (the resident) does something else. Record review of the Resident's 5 medical record revealed that the primary attending physician was notified on (MONTH) 14, 2013 at 10 PM, at which time the resident was placed on Level-One Suicide Watch precautions. During an interview with LN 5 on (MONTH) 20, 2013 at approximately 10:57 AM, they indicated they had not done a MDS re-assessment related to the change in condition in Resident 5. The staff person stated they believed the event(s) that took place on (MONTH) 13, 2013 did constitute a significant change in the condition of the resident, and that a MDS assessment would probably be indicated. The staff person stated that they became aware of the incident on (MONTH) 18, 2013, and that she asked LN 1 for guidance if an MDS assessment would be needed (LN 5 said they had been mentored by LN 1 related to their role). LN 5 said that LN1 responded by saying that they (the facility) needs to figure out a process for that. LN 5 reported that they have never completed a MDS when there has been a significant change in a resident condition during her tenure in her position at the facility I have never tried that yet. We have only done MDS assessments when they are scheduled .Like at 30 and 60 days. LN 1 was interviewed on (MONTH) 20, 2013 at approximately 11:04 AM and asked if the event(s) involving Resident 5 that took place on (MONTH) 13, 2013 would constitute a significant change in resident condition necessitating a MDS assessment. LN 1 stated that 'we rely on the social worker, and we (the facility) know (the residents) baseline behavior. LN was then asked what guidelines the facility is using to determine what constitutes or qualifies as a significant change in condition, and their response was there is no policy, we follow the MDS 3.0 guidelines. When asked if there should have been an MDS assessment completed, LN 1 said most of the time we focus on the physical changes of the resident, and sometimes not the mental changes . | 2018-07-01 |