| 98 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2017-11-08 |
323 |
E |
0 |
1 |
8YVD11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the root cause analysis to address medications known to contribute to falls, and monitor and modify the effectiveness of interventions for repetitive falls for 3 (#s 10, 12, and 16) of 25 sampled residents. Findings include: 1. Review of resident #10's Fall Data and Plan of Action forms, showed the resident fell four times, which included the following dates: 2/10/17, 4/13/17, 7/2/17, and 10/4/17. Review of resident #10's Root Cause for the fall, dated 2/10/17, showed, Elder - up walking in room. The Plan for new interventions showed, Keep door cracked at night in order to give her a bit of light and so we can keep an eye on her. The facility did not identify why the resident fell while she was walking. Review of resident #10's Root Cause for the fall dated 4/13/17, showed, was looking for a seat in day room after supper and fell trying to maneuver in a tight spot. The Plan for new intervention was walk her back from meal and sit her down in a chair - don't let her wander. The facility did not address the contributing cause of the fall. Review of resident #10's Root Cause for the fall dated 7/2/17, showed, tried turning around to sit down while maneuvering walker and lost balance and fell . The Plan for new interventions showed assist elder in backing up and sitting down. The facility did not address why the residents was unsteady while turning. During an observation on 11/7/17 at 12:40 p.m., resident #10 was walking in the day room with a walker and no assistance. Review of resident #10's Root Cause for the fall, dated 10/4/17, showed, fell when unassisted walk (stand by) on way to bathroom. The Plan for new interventions showed use gait belt and walker while ill with URI. The facility did not identify the contributing factors causing the fall. Review of resident #10's Comprehensive Fall Management Program form, for the falls dated 4/13/17, 7/2/17, and 10/4/17, showed no risk factors or interventions were marked on each form. During an interview on 11/7/17 at 8:35 a.m., staff member H stated the Fall Data form and the Comprehensive Fall Management Program form, replaced a fall care plan. Review of resident #10's Physician Orders, dated 11/7/17, showed resident #10 received a routine antianxiety, twice a day. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility addressed the medication as a possible contributing factor to resident #10's falls, but did not attempt to reduce or eliminate the medication. 2. Review of resident #12's Post Fall Evaluation form, dated 7/6/17, showed the resident fell five times, which occurred on: 2/21/17, 6/18/17, 6/27/17, 7/6/17, and 9/29/17. Review of resident #12's Root Cause for the fall, dated 2/21/17, showed, Elder slid out of recliner onto floor. The Plan for a new intervention showed Encourage elder to have feet elevated in recliner. The facility did not identify why the resident slid out of his chair. Review of resident #12's Root Cause for the fall, dated 6/18/17, showed, Elder rolled out of bed. The Plan for new intervention showed Keep bed in lower position and keep garbage and other hard object away from the bed. Elder was positive for a UTI. The facility did not identify why the resident rolled out of bed. During an observation and interview on 11/6/17 at 4:15 p.m., resident #12's room had three large bags of pop cans, stacked upon each other. A fall mat was folded up and against the wall, away from the bed. Resident #12 stated he did not use the mat. The mat was identified on the Fall Action Plan form as a fall intervention. Review of resident #12's Root Cause for the fall dated 6/27/17, showed, Elder lost balance. The Plan for new interventions showed positive for UTI. The analysis did not include the possible need for increased assistance or supervision for the resident. Review of resident #12's Root Cause for the fall dated 7/6/17, showed the resident had slid out of the recliner again. The Plan for a new intervention showed start 30 minute checks, and these were discontinued on 9/11/17. Review of resident #12's Root Cause for the fall dated 9/30/17, showed the elder rolled out of bed again. The Plan for a new intervention showed re-initiate 30 minute checks, and check urine for UTI. The facility did not identify why the resident rolled out of bed. During an interview on 11/6/17 at 4:15 p.m., resident #12 stated he was afraid of falling more than anything. Review of resident #12's Physician order [REDACTED]. The facility failed to attempt a dose reduction for the Seroquel (see F329). 3. Review of resident #16's Fall Data and Plan of Action forms showed the resident fell six times, from 10/1/17 through 10/28/17. Resident #16 was admitted to the long term care unit on 9/25/17. Review of resident #16's Root Cause for the fall, dated 10/1/17, showed elder was self transferring and fell . The Plan for a new intervention was, Therapy placed a second handle next to the toilet to assist with transfers. The analysis showed the elder had poor cognition and continued to attempt to transfer independently. The Root Cause did not show how toileting contributed to the fall. Review of resident #16's Root Cause for the fall, dated 10/5/17, showed the elder rolled herself out of bed. The Plan for a new intervention showed use a body pillow and fall mat. The Analysis showed elder continued to self transfer. The Root Cause did not show how or why the resident rolled out of bed, and how self transferring contributed to the fall. Review of resident #16's Root Cause for the fall dated 10/12/17, showed, Elder climbed out of bed, stood up at closet and when attempting to sit in the wheelchair, she fell . The Plan for a new intervention showed Place elder in recliner or bed when in room and remove wheelchair and walker from sight. If elder want (sic) to remain in wheelchair, encourage her to be in the day room. The facility did not address why she wanted to get out of bed, or the need for staff to anticipate and meet her needs. During an observation on 11/16/17 at 10:45 a.m., resident #16 was in her wheelchair, in her room. The walker was next to the recliner. The call light was placed on the recliner. When asked if she could reach her call light, resident #16 attempted to reach it, but her wheelchair got stuck by the recliner, and she was not able to reach it, therefore not able to call for assistance. Review of resident #16's Root Cause for the fall, dated 10/12/17, showed the elder was getting up to change the TV channel. The Plan for a new intervention showed 15 minute checks secondary to toileting, encourage elder to be in day room as much as she is willing. The intervention did not address why resident #16 was getting up to change the channel or why she fell when up. Review of resident #16's Root Cause for the fall dated 10/21/17, showed the elder attempted to get out of recliner while the resident's legs were extended. Staff caught her and lowered her to the floor. The plan for a new intervention showed Continue with 15 minute checks and keep recliner legs elevated, and pancake light strategically placed. Continue to encourage elder to be in dayroom. Elder continues to be impulsive. Review of resident #16's Root Cause for the fall dated 10/28/17, showed the elder attempted to get out of bed at 9:00 a.m., to go to the bathroom. The Plan for a new intervention was to toilet the elder during rounds and get resident up at night to use the bathroom. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility had implemented a new fall prevention program, which included fall reviews for three residents one day a week. She stated the team may not understand what root cause analysis meant. She stated the unit nurse managers were responsible for monitoring and evaluating the effectiveness of the fall interventions. Record review of Fall Action Plans and progress notes showed no documented monitoring or evaluation for the effectiveness of the interventions, after repeated falls. Staff member H stated, If they fall again, the intervention did not work. |
2020-09-01 |