cms_HI: 22
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
22 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 280 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's basic care plan for falls was revised for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: Cross-reference to findings at F323. Resident #77 (R #77) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R #77's 3/21/17 basic care plan was formulated by an interdisciplinary team (IDT) and included care plans for self care deficit, altered thought process, alteration in comfort and a risk for falls. During an interview with Staff #13 on 4/12/2017 at 2:04 PM, she acknowledged her 3/24/17 assessment of R #77 was not included in the basic care plan with regard to the resident's with left sided weakness, difficulty in communicating, confusion, and functional limitations in her mobility and transfer. Staff #13 said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview with Staff #55 revealed the family stated the resident fell all the time at home. Staff #55 confirmed the resident sustained [REDACTED]. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. This was in relation to Staff #13's progress note entry of 3/24/17 that based on her assessment of the resident, the recommended plan was to support R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. This was not found in the basic risk for falls care plan. R #77 then sustained a fall with a left shoulder subluxation (dislocation) injury on 3/25/17. Staff #55 acknowledged there should have been something more put in place and that Staff #13's assessment should have been part of it. She acknowledged as Staff #13 is also a licensed professional, her expectation was the staff speak in terms of a communication hand off and some of these things would have been added to the care plan. The facility failed to update/revise the resident's care plan following a therapist's assessment which may have prevented the fall injury from occurring. | 2020-09-01 |