| 52 |
GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER |
125004 |
3-3420 KUHIO HIGHWAY, SUITE 300 |
LIHUE |
HI |
96766 |
2016-10-28 |
323 |
D |
0 |
1 |
U50511 |
Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Finding include: On 3/7/16, an IR was filed with the SA regarding Resident # 68 who sustained an unwitnessed fall in the shower room on 3/4/16. The IR documented that Resident #68 was found laying on floor with their head up against (BR) bathroom wall. Resident #68 complained of left ribcage pain and bilateral hip pain. On 3/5/16, radiology department notified facility of left rib fracture. On 10/27/16 at 7:26 AM, Resident #68's Electronic Health Record review (EHR) and concurrent review with the Minimum Data Set Coordinator (MDS-C) dated 4/6/16 was done. In Section C. Cognitive level noted the resident scored a 4 on the Brief Interview for Mental Status (BIMS). According to the Centers for Medicare Services' Resident Assessment instruction (RAI) Version 3.0 manual, the BIMS is a brief screener that aids in detecting cognitive impairment 13-15: cognitively intact: 8-12: moderately impaired; 0-7 severe impairment. 10/27/16 at 7:31 AM, EHR review reveals a careplan with fall prevention interventions stating: 1) Provide one assist with stand pivot transfers from bed to wheelchair. 2) Check on Resident #68 frequently while resting in bed or while up in wheelchair. 3) Ensure laser alarm in place, on and functioning at all times when Resident #68 is in bed and care is not being given. 4) Ensure bedside mattress in place. 5) Assess for dizziness and allow to rest approximately 2-3 minutes prior to transfers from sitting to standing position. 6) Assess for side-effects of Mirtazapine use (twitching, abnormal thinking, restlessness, nausea, dizziness) and notify MD PRN. 7) Keep floor clean, dry and free of clutter. 8) Keep floor clean, dry and free of clutter. 9) Provide low bed. 10) Ensure clip alarm is attached to Resident #68's clothing and that it is located on the inside of their bed towards the wall when they are in the bed. 11) Ensure pad alarms are in place, on, and functioning at all times when care is not being given. Interview on 10/27/16 at 9:32 AM, MDS-C confirms that intervention #11 (Ensure pad alarms are in place, on, and functioning at all times when care is not being given) was added on 3/7/16 to the careplan after Resident # 68 fell on on 3/4/16. LN #1 acknowledged that intervention #11 was added to the careplan after the fall (Ensure pad alarms are in place, on, and functioning at all times when care is not being given). Interview on 10/27/16 at 10:00 AM with Resident #68. Resident #68 is able to recall their spouse and verbalize their needs. Resident # 68 stated that they would like to visit her spouse. Observation on 10/27/16 at 12:10 PM at bedside. Resident #68 was assisted out of bed and transferred to wheelchair to visit spouse. After transport to the Kona unit, this surveyor and CNA #1 went to check on assistive device - pad alarm. CNA #1 acknowledged that the pad alarm was in place; however, the alarm button was not turned on. CNA #1 turned on the alarm button which beeped and a green light was noted. On 10/27/16 at 3:11 PM, interview with Resident Care Manager #2 (RCM). RCM #2 stated that Resident #68 fell in the bathroom. RCM #2 could not remember if there was a certified nurses aide with Resident #68. 10/27/16 at 3:20 PM, Interview with LN#1 stated that We found Resident #68 on the floor with their head against the wall by themselves. Resident #68 is able to roll by themselves. We are not sure how Resident #68 got there. Immediately after the fall, Resident #68 complained of left rib pain and we called the MD. Resident #68 was x-rayed the next day. Resident #68 underwent restorative treatment as ordered also. Resident #68 would refuse pain meds. Resident #68 is now back to their baseline level. When asked how did Resident #68 get to the bathroom on their own? LN #1 stated that Resident #68 is able to propel themselves and staff will push Resident #68 as well. When asked if this as avoidable, LN #1 stated that yes, we could have been checking on Resident #68 more frequently and make sure they call for assistance. The facility could not provide a monitor sheet that showed how they frequently monitor and check the residents. LN #1 stated that Resident #68 has only had one fall in the last six months. |
2020-09-01 |