| 24 |
KULA HOSPITAL |
125003 |
100 KEOKEA PLACE |
KULA |
HI |
96790 |
2017-04-21 |
323 |
G |
0 |
1 |
1M3411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: A Stage 2 review was done based on an incident report (IR) involving a fall related injury sustained by Resident #77 (R #77). The facility's self-reported IR stated the resident's 3/25/17 fall appeared to have .more affected her shoulder which was already affected by the cva. She is forgetful at times and does not remember to use the call bell. She does not realize that the left side of her body does not support her anymore. What interventions were implemented after the incident/event to prevent further injury? Immediate measures: 1:1 supervision while in bed and visual supervision when out of bed. Toileting at least every 2 hours with the goal of working on promoting continence, PT/OT have done initial evaluations with resident on 3/23-24 and will be working with resident to increase physical capabilities which will help with all aspects of care and comfort. On site review found R #77 was admitted to the facility on [DATE] from the hospital with several [DIAGNOSES REDACTED]. The resident's chart review found her admission included rehabilitation services (physical and occupational therapy) and that she has confusion. The resident's unwitnessed fall occurred on 3/25/17 in her room, and at the time of the incident, she stated she wanted to go to the bathroom. As a result of the fall, R #77 sustained a left shoulder subluxation (dislocation) injury. The emergency department noted it was a difficult reduction of the shoulder injury and she was given a left arm sling to stay on for at least 7 days. Observation of the resident on 4/12/17 at 10:16 AM in the hallway found she still required the use of a sling. The resident was being assisted by nurses aides with Staff #13 instructing them how to apply a new cross-over type of sling to support her left shoulder/arm. The resident allowed the sling to be applied and spoke very few words to the staff in her native dialect. Chart review of the 3/24/17 therapy evaluation by Staff #13 found her assessment of the resident included, decreased mobility + ADL safety + independence, impaired cognition/safety awareness with impulsiveness and difficulty communicating. She remains aware of the need to toilet, sits for at least several minutes unsupported . Staff #13's plan was to recommend supporting 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. On 04/12/2017 at 2:04 PM, an interview of Staff #13 was done regarding her 3/24/17 evaluation of the resident. She was asked how she communicated her plan to the line staff caring for the resident. Staff #13 replied that if things need to be known immediately, she went directly to a nurse's aide or the nurse. She said if they were not available, she would document it on a sheet for the next shift to get it communicated forward, or speak with the head nurse to communicate it as quickly as possible and do a care plan update. She acknowledged she could update the care plan as well. Staff #13 recalled speaking to a licensed staff about the toileting and transfer for this resident and how important it was for staff to stabilize the other side as she (the resident) really doesn't put any weight on the other side and her ankle on the left side is unstable and can't put weight on it to transfer. Staff #13 thought it may have been added or implemented to the basic care plan and said nursing typically would put it in right away and that the resident came in with a history of falls. Staff #13 acknowledged the resident sustained [REDACTED]. She also said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. Staff #13 was informed that her plan/recommendations were not found in the care plan, which could have potentially prevented an injurious fall from 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 acknowledged that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview of Staff #55 was done. She affirmed she completed the IR because the DON was on leave. She said the family said R #77 fell all the time at home. She also said the emergency room physician said R #77's shoulder dislocation was a difficult reduction. 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. 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. Further review of the post-fall investigation report revealed some of the contributing factors to R #77's fall included the resident's inability to ambulate by herself (stand/pivot), that she was non-English speaking with a lack of safety awareness, she had a condition (tumor excision) resulting in left sided weakness, neurological memory loss causing her to forget she has the left sided weakness, an inability to remember to use her call light, and, that her bed alarm although activated on the bed, had not been activated on the display board. It also noted a lack of staff guidance related to points of communication/exchange (i.e., handoffs/shift reports). In addition, this resident on admission was noted with a history of frequent falls and Staff #55 stated this in her interview. Yet, these assessments were not done until after R #77 suffered the injurious fall to her left shoulder, causing injury to an already weakened left side. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 04/13/2017 at 10:22 AM, the DON acknowledged that harm due to the resident's fall with injury, occurred for this resident. During an interview with the Medical Director on 4/21/17 at 8:30 AM, she stated the communication piece was something they are looking to improve, and mentioned the SBAR method as an example on how to improve communication amongst the staff. The facility failed to fully assess the resident's known pre-disposition to frequent falls concomitant with her clinical condition/status on admission. There was an additional failure in communicating Staff #13's plan/recommendations and failure to immediately implement interventions into the resident's care plan to assure staff would be alerted to the resident's care needs. This failure may have contributed to the resident's subsequent fall and left shoulder injury on 3/25/17. |
2020-09-01 |