| 63 |
AROOSTOOK HEALTH CENTER |
205018 |
PO BOX 410 |
MARS HILL |
ME |
4758 |
2018-12-10 |
656 |
B |
1 |
0 |
246711 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, facility policy review, and interviews, the facility failed to follow a care plan in the area of falls for 2 of 3 residents reviewed (Resident #1, Resident #2). Findings: The facility's policy Fall Prevention/Assessment, revised 3/7/14, defines a fall as an unplanned descent to the floor, with or without injury to the patient and includes falls that a staff member attempts to minimize the impact of the fall by easing the patient's descent to the floor or in some manner attempted to break the fall. It includes a PR[NAME]EDURE that indicates it will be documented on the resident plan of care that they are at risk for falls, appropriate interventions will also be documented here, and to notify the provider (physician) and family/significant other of fall as soon as possible or if injury requires immediate treatment then notify the family immediately regardless of the time of day. This policy also directs staff to complete an incident report (RL6) and document facts relevant to the fall and any follow up actions. 1. Resident #1's care plan, under the care area of falls, included an intervention, dated 10/11/18, that directed staff to follow the facility fall protocol. Resident #1's clinical record contained a paper, dated 10/16/18, that identified 3 family members that can be contacted regarding concerns with Resident #1 and that the Resident Representative, listed as #1, is to be attempted to be contacted first. On 10/20/18 at 12:37 p.m., Registered Nurse (RN) #1 documented in the clinical record that Resident #1 tried to move him/herself to bed and landed on the floor and that the physician was informed of the incident. The facility was unable to provide an incident report (RL6) for this fall and there is no evidence of the Resident Representative being notified. On 10/29/18 at 7:52 p.m., RN #2 documented in the clinical record that at approximately 12 p.m., Resident #1 had a fall with no injuries. This note indicated the family and physician were notified. On 12/10/18 at 12:55 p.m., during an interview with a surveyor , RN #2 stated that she did not attempt to call the Resident Representative for Resident #1 but called the third person on the list and she did not complete an incident report (RL6) because she didn't have a pin number for access to the electronic system. On 12/10/18 at 11:55 a.m., during an interview with the Director of Nursing (DON), a surveyor requested the incident reports (RL6) for Resident #1's falls that were documented in the clinical record on 10/20/18 and 10/29/18. The DON was unable to provide an incident form for either date. The DON stated that both nurse's on duty those days were [MEDICATION NAME] and usually the ask another nurse on duty to complete the forms. The surveyor confirmed that there is no evidence of an incident report (RL6)completed or that the Resident Representative was notified of the incidents. 2. Resident #2's care plan, under the care area of falls, included an intervention, dated 3/29/18, that directed staff to follow the facility fall protocol. On 12/1/18 at 6:00 p.m., a Licensed Practical Nurse documented that Resident #2 was with no complaints from a fall that occurred on 11/29/18. On 12/10/18 at 1:25 p.m., during an interview with the Administrator, the surveyor requested to see a copy of Resident #2's incident report (RL6) for the 11/29/18 fall that was mentioned in a 12/1/18 nurse's note. On 12/10/18 at 2:33 p.m., during an interview with a surveyor, the DON stated that she found a Certified Nursing Assistant (CNA) Shift Report that indicated Resident #2 did have a fall on 11/29/18. The DON stated the RN #2 was on duty and did not complete an incident report (RL6) and this was the first time that the DON was aware of this incident. She also stated that we notify Resident #2's son regarding any falls. The surveyor confirmed that there is no evidence of an incident report (RL6) or a nurse's note in the clinical record regarding this incident and the Resident Representative was not notified of the incident. |
2020-09-01 |