| 15 |
ST LUKE'S ELMORE LONG TERM CARE |
135006 |
895 NORTH 6TH EAST |
MOUNTAIN HOME |
ID |
83647 |
2018-10-12 |
656 |
E |
0 |
1 |
SC7O11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed to develop and follow resident-specific care plans. This was true for 5 of 10 residents (#1, #5, #12, and #64) whose care plans were reviewed. The residents' care plans did not address the use of [MEDICAL CONDITION] medications, wheelchair positioning, preference to sleep in a recliner, and follow aspiration precaution interventions. This failure created the potential for residents to receive inappropriate or inadequate care with a subsequent decline in health. Findings include: A facility policy Nursing Assessment, effective 06/30/18, stated an individualized plan-of-care will be formulated as soon as possible upon admission and updated based on ongoing assessment and patient needs. The policy stated the plan of care will include goals and interventions established in collaboration with the patient, family/significant other/guardian, and care providers. The policy also stated an RN will review and revise the plan as warranted in collaboration with the other disciplines. This policy was not followed. 1. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's physician orders, dated 7/13/18, directed staff to provide [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth nightly and 0.25 mg every morning. On 8/23/18, an order for [REDACTED]. Resident #5's care plan, dated 5/22/18, documented the antianxiety medication was to help with Resident #5's worries she experienced over her children and family. The care plan did not identify specific behaviors Resident #5 exhibited related to her anxiety. On 10/11/18 at 3:30 PM, the DON and RCA stated the medication was for anxiety but could not identify the specific behaviors exhibited. 2. Resident #64 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Physician orders, dated 10/1/18, documented Resident #64 was to receive [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily, [MEDICATION NAME] (used to stabilize mood or for [MEDICAL CONDITION]) 100 mg by mouth daily, and [MEDICATION NAME] (an antianxiety) 0.5 mg by mouth 3 times daily as needed. A care plan, dated 10/11/18, documented Resident #64 had major [MEDICAL CONDITION] and was prescribed an antidepressant medication. The care plan documented the activities Resident #64 enjoyed and the common side effects of the medication, however, the care plan did not indicate the behaviors exhibited related to her depression. The care plan did not address the [MEDICATION NAME] or the [MEDICATION NAME]. On 10/11/18 at 3:30 PM, the DON stated Resident #64's [MEDICATION NAME] was used as a mood stabilizer. The DON stated Resident #64 asked for the [MEDICATION NAME] when she wanted it because she was cognitively intact. 3. Resident #12 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician progress notes [REDACTED].#12 had a [DIAGNOSES REDACTED]. Resident #12's physician orders, dated 10/5/18, directed staff to provide [MEDICATION NAME] (an antidepressant/sedative) 50 mg nightly. Resident #12's Care Plan did not identify [MEDICAL CONDITION]. There was no documentation of sleep monitoring in Resident #12's medical record. On 10/13/18 at 10:15 AM, the DON stated the facility did not monitor Resident #12's hours of sleep. 4. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/09/18 at 3:36 PM, Resident #1 was tilted back in his wheelchair at a table in the common area, with his feet dangling (no foot rests, and his legs could not reach the floor). At 3:39 PM, staff offered Resident #1 a shake drink, but did not reposition him. On 10/11/18 at 10:27 AM, Resident #1 was observed in the common area for a bowling activity. He was seated in his wheelchair and his feet did not reach the floor. Resident #1's care plan did not address a tilting wheelchair or positioning in the wheelchair, ie. a foot rest. On 10/11/18 at 4:40 PM, the Compliance Director stated Resident #1 refused the foot rests, so when he is tilted back, his feet did not touch the floor. She stated he just received a new wheelchair and it was not yet in the care plan. The Compliance Director was unsure of when Resident #1 received the new wheelchair. On 10/12/18 at 9:39 PM, the DON stated the expectation was Resident #1's refusal of wheelchair footrests and positioning were in the care plan. On 10/12/18 at 12:20 PM, RN #1 stated Resident #1's feet were usually on the floor or on the legs of the table, she had not seen them dangling. She stated he has had his new wheelchair for a couple months now. |
2020-09-01 |