| 6251 |
SAFE HAVEN CARE CENTER OF POCATELLO |
135071 |
1200 HOSPITAL WAY |
POCATELLO |
ID |
83201 |
2011-01-04 |
280 |
D |
|
|
ZSO711 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility reported incidents, record review and staff interview it was determined the facility failed to ensure care plans were updated to include necessary goals and interventions related to 1:1 staff supervision for 1 of 11 sample residents reviewed who required 1:1 supervision (Residents #4.) Findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His admission MDS assessment, dated [DATE], identified the resident: * required one person physical assist for dressing and eating, two plus physical assist for toilet use, personal hygiene and bathing * was severely impaired in cognition and was easily distracted * had periods of altered perception or awareness of surroundings * had periods of restlessness and repetitive physical movements, wandering * had mental functioning which varied over the course of the day, with socially inappropriate/disruptive behavioral symptoms, and resisted care * was rarely/never understood/understands and had no speech. The admission physician's orders [REDACTED]. * "1:1 24 (hours per day)..." The Physician order [REDACTED]. * "Mechanical soft diet. Double portions. Thin liquids. Offer finger foods as much as possible * May have regular diet on special occasions * 1:1 staffing 24 hr (hours) a day R/T (related to) elopement risk/profound MR with autism/lack of safety awareness. May staff 2 on 1 PRN (as needed) if resident behaviors escalate..." The resident's [DATE] care plan, updated on [DATE], contained no documentation that the resident was to have 1:1 staff coverage on a 24 hour basis, and contained no direction to staff regarding their responsibilities for the 1:1 assignment, such as their proximity to the resident, line of sight, etc. The care plan, under the section, Nutritional Risk, contained handwritten entries which appeared to be in three different staff's handwriting. Intervention #17 stated, "resident frequently eat (sic) his food in a very fast manner (.) Staff to monitor." There were no staff initials or date next to this entry. The resident's undated Carry Care, utilized by CNAs, contained one direction to staff regarding 1:1 observation/care: "May trade with one on one staff as needed to prevent staff burn out." There was no direction to staff regarding monitoring the resident while eating. On [DATE] at 3:29 p.m., the Administrator contacted the BFS by telephone that Resident #4 had died following a food choking incident. The Abuse Hotline report from the facility documented in part: "[DATE], approx(imately) 6:50 pm...Res(ident) passed away d/t (due to) blockage in airway despite staff involvement and EMT intervention." CNA #4 was assigned to provide 1:1 supervision at the time of the choking incident. CNA #4's written statement, dated [DATE], included in part: "...I had gotten (Resident) an extra plate of food because he was still hungry after eating his first tray of food. He sat down on his bed & started eating a roast beef sandwich. He had eaten two already with no difficulty. I thought to cut it up. It was a big piece of meat on top of bread with gravy on it. Because (Resident) hadn't had an issue with the 2 previous sandwiches he'd eaten I didn't cut it up. I went into the hall. I was standing near his room when he ran out, not a minute after I'd left. He was choking. He ran to the nurses station at (name of unit). (Speech Therapist) was there. I asked her to get a nurse. (Resident) was wheezing, getting some air but not enough. He ran down (a second unit hall) about half way. I started doing [MEDICATION NAME] thrusts..." NOTE: The CNA's statement was an acknowledgement that he was not performing visual observation of the resident. He did not see how the resident was eating or observe the actual onset of choking to be able to immediately call for assistance and start emergency intervention before the resident ran out of his room, ran to the nurses station, then ran down the hall. The facility's final report, however, documented the CNA was "monitored as closely as possible while eating his sandwich" and "Res plan of care followed, staff assisted appropriately." On [DATE] at 3:45 p.m. the Administrator and DON were interviewed in regard to specific 1:1 supervision provided to Resident #4. The Administrator stated the resident had been "monitored closely" at the time of the incident. He further stated that it was the facility practice to monitor the resident from the door if the close presence of staff agitated the resident. Documentation of the incident did not include information on the state of agitation of the resident, and the care plan failed to include instructions for 1:1 staff on what to do if the resident was agitated. No further documentation or information was provided for review on Resident #4's care plan. Refer to F323 as it related to the immediate jeopardy finding associated with Resident #4 and 1:1 supervision. |
2014-04-01 |