cms_MT: 974
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 974 | CLARK FORK VALLEY NURSING HOME | 275107 | 10 KRUGER RD | PLAINS | MT | 59859 | 2018-03-08 | 689 | E | 0 | 1 | GWLR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to identify root cause, investigate staff-associated falls, implement interventions, and monitor and modify interventions to prevent multiple falls for 3 (#s 5, 13 and 11) of 12 sampled residents. Resident #13 had a laceration to the head and a skin tear from falls, and resident #11 had scratches and bruises from a fall. Findings include: 1. Review of the Care Area Assessment for falls, noted 12/29/17, showed (Resident) triggered for fall due to receiving [MEDICAL CONDITION] medications, and for impaired balance. (Resident) had [MEDICAL CONDITION] (YEAR), with residual right sided weakness as well as communication deficit. She has not attempted to self transfer from bed or wheelchair since admission. Staff has been using a tab alarm when she is in wheelchair to alert them for unintended position changes which could result in a fall. Review of resident #13's progress note, dated 1/3/18, showed Resident slipped during AM care transfer, hitting head on bedside door pull resulting in 2 cm laceration left of midline of forehead. Resident assisted back to bed. Area cleansed and 2 steri strips applied. Review of resident #13's progress note, dated 1/17/18, showed Resident found laying head first on the floor with legs caught in the wheelchair legs. Wheelchair removed. Bleeding noted from skin tears to right hand and [MEDICAL CONDITION]. Taken to ED. Review of resident #13's Care Plan for falls, dated 1/22/18, showed the resident fell on [DATE], during a CNA transfer, and fell from her wheelchair on 1/17/18. Review of resident #13's progress note, dated 1/26/18, showed Resident found on her knees near her bed. Mat had been placed on floor this am, and was in place upon entering room. No injury noted. Review of resident #13's progress note, dated 2/24/18, showed Resident on her knees on floor pad leaning over bed. Tab alarm still intact. Further review of resident #13's care plan showed interventions which were: - Extensive assist to dependent for transfers. Use stand-up lift as needed. Let her know each step of process before proceeding. Go Slow. Right foot may turn medial when she is on the lift, and she has indicated right arm pain with sling use. - Tab alarm while seated in wheelchair to alert staff when leans to the right or forward. - Has not tried to self transfer but hangs her legs off of side of bed at night. - Wheelchair with back that leans back for more comfortable positioning and to decrease risk of falling forward. During an observation on 3/6/18 at 3:10 p.m., resident #13 was in her room, kneeling on her fall mat on the floor. During an interview on 3/7/18 at 8:45 a.m., staff member A stated the facility did not have fall investigations. She said the facility did an investigation, but it was not part of the medical record. Review of resident #13's progress notes, care plan, and Care Area Assessment, did not show the root causes of her four falls, particularly for a staff-related fall, and did not show interventions to prevent falls, contributing factors, or if monitoring of the resident for fall safety was adequate. During an interview on 3/8/18 at 10:34 a.m., staff member A stated falls were discussed and trended at the Quality Assurance meeting, but the facility did not show documented specifics for fall reduction. 2. Review of resident #11's Care Area Assessment, dated 3/30/17, showed the resident had been swung off balance in the stand-up lift, and was lowered to the floor. Her bed was exchanged with a new bed that would accommodate the use of the lift. Review of resident #11's nursing progress note, dated 3/6/18, showed While being prepared for shower in shower room, resident leaned forward while in shower chair as it was being rolled over shower drain and resident tipped forward onto left side on floor. Small scratch above left knee and small bruise left shoulder noted. During an interview on 3/8/18 at 9:30 a.m., staff member A stated the facility had no investigations to share for #11's falls. Review of resident #11's Care Area Assessment, showed No falls since 3/30/17. 3. During an interview on 3/6/18 at 10:20 a.m., resident #5 stated she had fallen recently. She was unable to report when the falls occurred, or what had happened, but she believed one fall was very recent. Review of resident #5's progress notes, dated 9/8/17-3/5/18, showed the resident had two falls during this period. A progress note, dated 11/2/17, showed resident #5 was observed, by the nurse, to be lying on the floor. The note did not show how resident #5 came to be on the floor, what she was doing prior to being on the floor, or if resident #5 sustained any injury. A progress note, dated 3/1/18, documented as a late entry for 2/28/18, showed resident #5 was pulling on her bed sheet, lost her balance, went down onto her knees and then fell to the right. The progress notes did not show a root cause analysis of why resident #5 had fallen, or if the staff had identified contributing factors, if monitoring was adequate, or what the interventions were to prevent future falls. A written request was made for the fall investigations for resident #5 from (MONTH) (YEAR) through (MONTH) (YEAR). No documentation was provided. No directions were provided for where this information would be found in the paper medical records or in the electronic medical records. Review of resident #5's fall care plan, last edited 3/5/18, showed she had four falls in (YEAR). The fall of 2/28/18, was not noted on the care plan. Resident #5's care plan included a list of interventions for fall prevention. None of the interventions were dated for when the intervention was implemented to show the plan was evaluated or modified based on effectiveness of the interventions. The care plan did not show if the interventions were related to a specific event. During an interview on 3/7/18 at 2:50 p.m., staff member V stated resident care plans were not necessarily updated after a fall. She said the care plan would not likely be updated if the resident was known to have fallen before. Staff member V stated new interventions were not always added after a fall. She stated she could not say if new, resident-specific interventions, were added after resident #5's falls. During an interview on 3/7/18 at 2:59 p.m., staff member B stated new interventions were discussed at the RICC meeting. During an interview on 3/8/18 at 2:10 p.m., at the conclusion of the survey, staff member A stated she had not understood that documentation was still needed regarding fall investigations. She was advised that the information could be faxed to the State Survey Agency. No documentation was received regarding fall investigations. The facility failed to show preventative efforts for falls. Review of a document, labeled Fall Investigations, provided to the State Survey Agency after the conclusion of the survey, showed a summary of the resident #5's falls on 11/2/17, and 2/28/18. The summaries failed to show the investigation of the root causes for the falls, in an attempt to prevent future falls for the resident. | 2020-09-01 |