| 6306 |
RIVER RIDGE CENTER |
135106 |
640 FILER AVENUE WEST |
TWIN FALLS |
ID |
83301 |
2010-10-22 |
241 |
D |
|
|
84X411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview and record review, it was determined the facility failed to promote the dignity of residents by speaking respectfully to residents (#8), failed to ensure resident's visual privacy was maintained when the resident was wheeled backwards down the hall from the shower (#18) and failed to ensure a resident was assisted to bed when the resident desired (#2). This was true for 2 of 10 sampled residents (#s 2 & 8) and 1 random resident (#18). Findings included: 1. Resident #8 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 8/8/10, coded: * Short and long term memory problems * Severely impaired cognitive skills for daily decision-making * Rarely/never understood * Rarely/never understands Resident #8's Care Plan identified the problem, dated 10/16/09, "Altered cognitive status and communication deficit AEB (as evidenced by): short and long term memory problem, impaired decision making, confusion, and disorientation to person, place and time." Interventions for this problem included: * "Use pleasant interaction to reassure him when confused... * Gently attempt to calm and redirect focus when anxious or frustrated. * Attempt to make him secure and safe. * Reassure (Resident #8) he is secure and safe." The Care Plan, additionally, identified the problem, dated 10/16/09, "Potential for mood impairment related to dementia..." Interventions for this problem included: * "Offer praise and support and positive comments when indicated. * Encourage staff to assist him as needed, being kind and non threatening..." On 10/19/10, between 8:25 am and 9:20 am, Resident #8 was observed in the Solana dining room. The resident was set-up with the breakfast meal at 8:25 am. No staff assistance was provided during the entire meal. At 8:45 am, the resident had finished the eggs on the plate and poured some of his hot cereal onto the plate. The resident then poured the milk, juice and coffee onto the plate, filling the plate to the rim. The resident used a spoon to attempt to eat the mixture, spilling the mixture over the sides of the plate. The resident also dipped his fingers onto the plate stirring the mixture. At 9:20 am, CNA #2 noticed the resident's plate and stated to the resident, "We're done playing here" and removed the plate. On 10/20/10 between 12:15 pm and 12:55 pm, Resident #8 was observed in the Solana dining room. The resident started to remove his non-skid socks at 12:15 pm and completed the removal of both socks by 12:25 pm. The resident was then barefooted. At 12:47 pm, CNA #2 brought in Resident #8's lunch tray and stated, "Hey (Resident #8). I'll wash my hands and feed you." CNA #2 then noticed Resident #8 did not have his socks on and was barefooted. She stated to the resident, "You can have your socks when you are done (with your meal)." CNA #2 began to assist the resident to dine without placing the resident's socks on the resident. At 1:00 pm, the Nurse Manager was informed that Resident #8 was in the dining room barefooted while eating lunch. The Nurse Manager stated, "In the dining room we try to encourage foot wear. I'll address it." She went to the dining room to resolve the issue. On 10/20/10 at 5:00 pm, the Administrator, DON and Nurse Consultant were informed of the issues. No further information was received from the facility. 2. Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], documented she was cognitively independent (decisions were consistent and reasonable). During interview with the resident on 10/20/10 at 10:50 am, she said that the night before she was not put to bed until 12:00 am. She was visibly upset by this and strongly related again, that she had looked at the clock when they finally put her down and it was 12:00 am. The resident was pointing to the clock in her room at this time, and stated she had looked right at the clock. The resident then described the CNA who came in to help her. Resident #2 stated the CNA did not know a thing, and the resident had to tell her how to do everything, to get her ready for bed. The resident stated there should have been another helper on the hall. The resident said she asked the CNA where the other assigned CNA was, and why it had taken so long to help her. Resident #2 said the CNA just kept saying, "I don't know." The resident stated that she was very easy to get ready for bed, "They don't have to do much for me." Resident #2 said the staff frequently got her to bed later than she would like, but not always as late as 12:00 am. The resident was frustrated and felt ignored by staff as she sat in her room waiting to be helped to her bed. 3. Random Resident #18 was observed on 10/19/10 at 7:20 am. The resident was being pushed in a shower chair out of the shower room at the beginning of the 200 hall. After the CNA got her out the door the resident was pushed backwards through the nurses' station and public entrance area, past the Medicare dining room and up the 100 hall to her room. Resident #18 had wet hair, was covered with a hospital gown and a flannel blanket over her legs. Her bare legs were observed from the back of the shower chair. She was then pushed into her room for assistance with ADL care. |
2014-04-01 |