| 2 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2017-03-09 |
246 |
E |
0 |
1 |
KTFZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to furnish a table which accommodated the ability for 2 (#s 19 and 36) of 36 sampled and supplemental residents to feed themselves. The facility, at Westview, failed to accommodate wheel chair bound residents in 37 of 37 bathrooms, giving them the ability to see themselves in their bathroom mirrors. The facility failed to ensure 1 (#7) of 24 residents was accommodated with a bathroom doorway wide enough for entry. Findings include: 1. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required assist with meals. During an observation on 3/6/17 at 4:35 p.m., resident #19 was observed in the Lodge dining room. The resident was seated in a smaller than usual Broda chair. The resident had poor head control and was bent forward, resting her hand on her chest. The resident's chair was pushed up to a table, farthest from the Lodge kitchenette. The table was level with resident #19's nose. The resident was drinking hot chocolate out of a plastic, lidded glass, with a straw. The resident had to reach up to the table to place her glass on the table top. The glass wobbled, tipped. The resident was unable to see up on the tabletop. During an interview on 3/6/17 at 4:35 p.m., resident #19 stated, Might would help if the table was lower, to eat by herself. During an observation on 3/7/17 at 4:43 p.m., resident #19 sat at the table farthest from the Lodge kitchenette. The resident was in a small broad chair. The table was at nose level. A plate with a half of a peanut butter/jelly sandwich was on the table in front of the resident. The resident tried to reach the sandwich. The resident was unable to grasp the sandwich. The resident was able to grab the plate, and pull the plate with the half sandwich to her lap. Staff member V placed the plate back on the table and cut a small piece out of the middle of the sandwich and encouraged resident #19 to eat the bite. Staff member V left the side of resident #19. -At 5:01 p.m., resident #19 was reaching for an almost empty glass, secured with a lid and straw. The glass fell sideways on the table, dripping white liquid content from the glass onto resident #19's lap. -The resident tried lifting the glass to drink, again. After sipping the drink with a straw, the resident lowered her head towards her chest, hitting the edge of the table with her forehead. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in a small broad chair, against the table, farthest from the Lodge dining room kitchenette. The resident's nose was level with the table top. During an observation on 3/9/17 at 9:30 a.m., resident #19 was seated in the Lodge dining room. The table had been lowered to shoulder level. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the resident, as long as she could remember, was to have a lowered table for meals. Review of the interdisciplinary notes, dated 1/1/17, showed the resident had a bruise on her right eye due to bumping her head on the table in the dining room. Staff were educated to not push the resident too close to the table at meals, and the table was raised a bit to prevent the resident from bumping her head on the table. Record review showed a lack of documentation involving the table height, during meal times, for resident #19. 2. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 3/8/17 at 5:40 p.m., resident #36 was in the dining room waiting to eat dinner. Resident #36 was sitting at a round table with both her feet extended in front of her. Resident #36 was placed at the table with her left side closest to her plate. Resident #36 was reaching across her body, with a fork in her right hand. She would spear food with her fork, and bring her right hand back to the middle of her body to place the food in her mouth. Resident #36 was observed to eat 20 percent of her meal. During an interview on 3/8/17 at 5:40 p.m., resident #36 said it would be easier for her to eat if her food was placed in front of her. When resident #36 was asked if a bedside table, that could be placed in front of her, would be better, resident #36's comment was, Well sure! Then I wouldn't have to reach across myself to eat. Resident #36 then said, But they'll never think of that here. During an interview on 3/8/17 at 5:50 p.m., staff member HH said resident #36's feet were very sensitive, and needed to stay elevated. Staff member HH said she did not know if the facility had ever addressed using a bedside table for resident #36 during meals. Staff member HH said they would try a bedside table, at breakfast, for resident #36. During an observation and interview on 3/9/17 at 8:45 a.m., resident #36 had a bedside table placed in front of her. Her food was on the table, and resident #36 was eating breakfast. Resident #36 said it was easier to eat her food with it sitting in front of her. Resident #36 had eaten 85 percent of her breakfast. 3. During an interview on 3/9/17 at 8:00 a.m., resident #7's family member voiced several concerns for the resident: -The family member said if resident #7's wheelchair could fit through the bathroom door, resident #7 would be able to brush her own teeth, and wash her own face, which would allow resident #7 to be more independent. The family member said the mirror above the sink was to high, and resident #7 would not be able to see herself in it, if she could fit her wheelchair into the bathroom. -The family member said resident #7 had the ability to transfer herself from one surface to another. The family member said if resident #7 would toilet herself if her wheelchair could fit through the doorway of the bathroom. The family member said resident #7 could use a walker at times, and could get into the bathroom in that manner, but with trying to steady the walker, and grab the assist rails around the toilet, resident #7 was not, at times, able to get her pants down prior to her bladder releasing. The family member said the facility wanted resident #7 to use a bedside commode instead of the toilet. The family member said resident #7 was not comfortable with doing that, but at times she would. During a review of resident #7's Annual MDS, with an ARD of 8/6/16, showed the resident to be an extensive assist of 1 person for personal hygiene. This Annual MDS also showed the resident had no range of motion limitations. During an interview on 3/9/17 at 11:00 a.m., staff member T said there were several residents who could wash their faces, and brush their hair if they could get their wheelchairs into their bathrooms. Staff member T said resident #7 could do that for sure, if her bathroom door was wider so she could get in her bathroom. 4. Observations made from 3/6/16 to 3/9/17, throughout the Westview facility, showed all the mirrors in the resident bathrooms were at the same height above the bathroom sinks. Residents in manually operated wheelchairs were unable to view themselves in the bathroom mirrors. |
2020-09-01 |