cms_ND: 11
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2019-05-16 | 607 | D | 0 | 1 | FA2L12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement abuse investigation policies regarding injuries of unknown origin for 1 of 13 sampled residents (Resident #9) reviewed during the on-site revisit. Failure to assess, monitor, and investigate injuries of unknown origin placed Resident #9 at risk for abuse/neglect. Findings include: Review of the facility policy titled Abuse Investigation and Reporting occurred on 06/18/19. This undated policy stated, . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Review of Resident #9's medical record occurred on (MONTH) 17-18, 2019. [DIAGNOSES REDACTED]. At risk for alteration in skin integrity related to: impaired mobility, spending more time in bed, decrease in appetite, wheel self around and often scratch self on walls or on objects in room and bathroom . Interventions . Observe skin condition with ADL (activities of daily living) care daily; report abnormalities . Current physician's orders included geri sleeves (long sleeves ok) on in AM (morning) off at HS (bedtime). A weekly skin assessment, dated 06/15/19, identified no skin issues. Observation on 06/17/19 at 12:41 p.m. showed Resident #9 had bruising/swelling and a skin tear covered with a Band-Aid to her left hand, bruising to her right forearm and shin, and wearing a short-sleeved shirt without geri sleeves in place. The certified nursing assistant (CNA) (#1) stated she did not know how the injuries occurred. Observation on 06/17/19 5:10 p.m. showed Resident #9's left hand covered with a [MEDICATION NAME] dressing and no geri sleeves in place. Review of Resident #9's treatment administration record (TAR) on 06/17/19 at 5:36 p.m. showed staff signed off the geri sleeves for the morning of 06/17/19; however, observations throughout the day on 06/17/19 showed staff failed to apply Resident #9's geri sleeves. A nurse's note, dated 06/17/19 at 11:55 p.m., stated, . area was cleaned and miplex (sic) applied . The record contained no further assessment/description of the bruising/skin tear. During an interview on the afternoon of 06/18/19, a supervisory nurse (#2) agreed direct care staff should report injuries of unknown origin to the nurse. | 2020-09-01 |