cms_ID: 47
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 47 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 689 | G | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide sufficient supervision to meet resident's needs. This was true for 2 of 3 residents (#4 and #20) reviewed for supervision and accidents. Resident #20 was harmed when she sustained multiple injuries requiring medical evauation and care when the facility failed to implement interventions to prevent reoccurring falls. Resident #4 had multiple falls related to failure to implement the plan of care, ensure the bariatric extenders were locked . Findings include: The facility's policy and procedure for Fall Response and Management dated 11/28/17, directed staff to implement immediate interventions to prevent a repeat fall, to complete a post-fall investigation and event report, to review the post-fall evaluation and investigation, determine the cause, and to revise the care plan with interventions. The facility's policy and procedure for Accidents and Supervision to Prevent Accidents, dated 11/18/17, documented the following: *The facility staff observed, identified, and resolved potential hazards in the environment, while they took into consideration the unique characteristics and abilities of each resident. * The staff examined hazard and accident risk information for potential causes of accidents, and created interventions to reduce the risk of the hazard. * The facility monitored to confirm interventions were in place, evaluated interventions for efficacy, and changes and/or replaced interventions that were not effective. * The facility provided sufficient supervision to avoid accidents. The above policies were not followed. Examples include: 1. Resident #20 was readmitted to the facility 2/5/18 with multiple [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], documented Resident #20 was moderately cognitively impaired. Resident #20 experienced four falls in (MONTH) (YEAR). a) A Post Fall Investigation, dated 4/3/18 at 12:35 AM, documented Resident #20 was in bed under a weighted blanket. Resident #20 got out of bed and the floor alarm sounded. Resident #20 fell and hit her head on the corner of her night stand. A Progress Note dated 4/3/18 at 12:35 AM, documented Resident #20 had an unwitnessed fall. She was found in her room at 12:35 AM, lying on her left side. Resident #20 was bleeding from a laceration to her left forehead. Resident #20 complained of left hip pain and neck pain. She was sent to the emergency room . A Progress Note dated 4/3/18 at 3:30 AM documented Resident #20 returned to the facility at 3:30 AM with negative x-ray results and that her head was glued and ster stripped. A progress note dated 4/4/18 at 10:02 AM, documented Resident #20 sustained a laceration to her left forehead and bruising to her left face as result of the 4/3/18 fall. A Resident Monitoring Tool dated 4/3/18, documented Resident #20 was observed at 12:15 AM and 12:30 AM in bed and asleep. An Event Committee Follow Up Note dated 4/3/18 at 10:02 AM, documented Resident #20 was wearing regular socks, and the facility would re-educate staff to provide Resident #20 with no-skid socks. A care plan, dated 2/5/18, documented Resident #20 had no-skid socks were initiated on 2/26/18. b) A Post Fall Investigation dated 4/21/18 at 9:45 PM, documented Resident #20 stood up from her wheelchair and fell on her right side. She hit her head on the door frame, sustained a bump on her right forehead, and sustained two small skin lacerations on her arm. A progress note dated 4/22/18 at 9:00 AM, documented Resident #20 was transported to a clinic due to complaints of side pain. The physician diagnosed a right rib fracture and pneumonia. A Resident Monitoring Tool dated 4/21/18, documented Resident #20 was not monitored with 15-minute checks from 6:00 PM to 10:00 PM. An Event Committee Follow Up Note, dated 4/23/18 at 9:37 AM, documented checks would be done every 15 minutes from 6:00 PM to 6:00 AM. Resident #20's care plan dated 2/5/18, directed staff to perform 15-minute checks from 6:00 PM to 6:00 AM, and was initiated on 2/26/18. c) A Post Fall Investigation dated 4/26/18 at 7:45 PM, documented Resident #20 was found in a seated position near her bed. Resident #20 stood up at the bedside from her wheelchair and the wheelchair rolled backwards. She was uninjured. Resident #20 was last seen at 7:00 PM. A Resident Monitoring tool dated 4/26/18, documented Resident #20 was in the bathroom and engaged with staff from 7:30 PM to 8:15 PM. The documentation was written over to say in bed and engaged with staff. This was inconsistent with the Post Fall Investigation which stated Resident #20 was last seen by staff at 7:00 PM. Resident #20's care plan dated 2/5/18, documented anti-roll back brakes were initiated for Resident #20 on 4/27/18. d) A Post Fall Investigation dated 4/30/18 at 7:30 PM, documented Resident #20 had an unwitnessed fall with significant injury. Resident #20 was found on the floor in her room. She was on her right side and found to have a cut over her right eye. She stated she hurt her head. She had been in her wheelchair. A Resident Monitoring tool dated 4/30/18, documented Resident #20 was seated in her chair from 6:30 PM until her fall at 7:45 PM. Resident #20 was engaged with staff while seated in her chair at 7:00 PM. On 6/14/18 at 9:43 AM, the DON stated to prevent falls, the facility would place the resident on the Falling Star Program, place them on every 15-minute checks, and/or use a weighted blanket to help residents feel safer in bed. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including a history of falling, other abnormalities of gait and mobility, and [MEDICAL CONDITION] without behavioral disturbance. Resident #4's annual MDS assessment, dated 12/26/17, documented a moderate cognitive impairment, setup help only with transfers, one person physical assistance with ambulation, and one fall since the prior assessment. Resident #4's quarterly MDS assessment, dated 3/22/18, documented a moderate cognitive impairment, two person physical assistance with transfers, one person physical assistance with ambulation, and two or more falls since the prior assessment. Resident #4's current care plan documented he was at risk for falls, and had a history of [REDACTED]. * Assess his fall risk, completing assessments to identify the risk for falls. * Ensure the call light is within reach and encourage him to use it. * Encourage him to request assistance with ambulating. * Follow the facility fall protocol was initiated on 2/20/17. * The falling star program to identify his fall risk was initiated on 2/20/17 and revised on 4/24/18. * Non-skid footwear, non-skid socks was initiated on 2/20/17 and revised on 1/3/18. * PT to evaluate and treat and non-skid strips by the bed were initiated on 1/3/18. * Self-locking brakes to his wheelchair and non-skid strips on the bathroom floor were initiated on 3/21/18. * Encourage him to sit in the wheelchair while bedding is changed was initiated on 6/5/18. Resident #4's I and A reports documented the following: * A fall on 1/2/18 at 9:15 PM when he was in the wheelchair, attempted to remove his socks, and his feet slipped. * A fall on 2/8/18 at 7:00 AM when he fell out of bed while trying to reach the television's remote control. * A fall on 3/20/18 at 10:25 AM when he was unattended in the bathroom and lost his balance after standing up from the toilet. * A fall on 3/20/18 at 9:05 PM, when he attempted to self-transfer from the wheelchair to bed, forgot to lock the wheelchair brakes, and the wheelchair slid out of under him. * A fall on 6/5/18 at 5:15 AM when he was sitting on the edge of the bed as the CNA changed the bedding and he slipped off the edge of the bed. Resident #4's Progress Notes documented the following: * On 1/3/18 at 9:18 AM: He fell on [DATE] at 9:15 PM when standing by his bed to turn down the bedding. He was wearing socks and no shoes. Non-skid strips were added by the bed, non-skid socks were provided, and therapy was to continue. * On 2/9/18 at 7:04 AM: A large abrasion and red area were present on his abdomen. Neuro checks were good and he continued to self-transfer. On 2/9/18 at 2:38 PM: An environmental review was performed by the maintenance supervisor, and it was found the bariatric extenders were not locked into place. Will educate housekeepers and all staff when moving bed from one room to another to ensure (the) frame (is) locked into position on bariatric beds. * On 3/20/18 at 11:20 AM: The nurse was notified at 10:25 AM that the resident was found sitting on the bathroom floor, and he said he slipped when getting up from using the bathroom. Staff reported the resident was depressed the day before and was slightly confused. * On 3/20/18 at 9:05 PM: He was found on the floor between the wheelchair and bed, and said he attempted to transfer from the wheelchair to the bed, forgot to lock the wheelchair brakes, and the wheelchair rolled out from under him. He was asked to wait for assistance with transfers. * On 3/21/18 at 9:34 AM: The event committee discussed the falls on 3/20/18. Non-skid strips were added to the floor in front of the toilet, self-locking brakes were added to the wheelchair, therapy was to continue, and the resident was educated to wait for assistance with transfers. * On 6/5/18 at 7:09 AM: He was assisted to the floor by a CNA as she was changing his bed. * On 6/5/18 at 7:29 AM: The nurse was called to the resident's room and the resident was sitting/kneeling on his knees. He was assisted back to bed with 3 person assistance and a Hoyer lift. * on 6/5/18 at 9:02 AM: The event committee discussed the fall on 6/5/18. Resident #4 slid off the side of the bed and the CNA assisted him to his knees. Staff were inserviced regarding having the resident sit in the wheelchair while changing the bedding, the resident was encouraged to sit in the wheelchair while staff change his bedding, and therapy was continue. On 6/12/18 at 9:38 AM, Resident #4 said a couple of weeks ago and his legs gave out, and he had fallen quite a bit since being admitted to the facility. On 6/15/18 at 10:54 AM, CNA #6 said Resident #4 had fallen, one time from his chair and one time out of bed. CNA #6 said staff was helping him in the morning, made sure he was scooted back in his bed, therapy was working with him, and the staff walked with him at meal times. On 6/15/18 at 11:24 AM, RN #2 said Resident #4 had fallen, he slid to the floor during the previous week and he was kneeling next to his bed. RN #2 said the CNA was there when the resident slid to the floor, and RN #2 thought he was out too far on the bed. Staff were educated that sitting on the edge of the bed was not the best place for the resident when making the bed. RN #2 said Resident #4 had issues with spontaneity, non-skid strips were added next to the toilet, and the resident was educated about wearing non-skid socks. RN #2 said there was another fall when Resident #4's wheelchair rolled out from under him, and non-rolling brakes were added to the wheelchair. On 6/15/18 at 12:10 PM, the DON said Resident #4 fell on [DATE] and the physician should have been notified. The DON acknowledged there were blank areas on the Accident and Investigations and said there were blank areas that should have been filled in. The DON said staff were inserviced after the fall on 2/8/18 to make sure Resident #4 could reach the remote control. | 2020-09-01 |