| 56 |
MINOT HEALTH AND REHAB, LLC |
355031 |
600 S MAIN ST |
MINOT |
ND |
58701 |
2019-06-11 |
689 |
D |
1 |
0 |
HFFF11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > THIS IS A REPEAT DEFICIENCY FROM SURVEYS COMPLETED ON 07/26/17 and 08/16/18. GAIT BELT USE 1. Based on observation, record review, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 3 of 4 (Resident #3, #14, and #15) observed during a gait belt transfer. Failure to properly use a gait belt during transfers placed the resident at risk of accidents and injury. Findings include: Review of the facility Gait Belt Skill Checklist occurred on 06/10/19. This list stated, . properly position gait belt low on resident waist . Properly grasp belt for effective use . Assist resident from a sit to stand position grasping gait belt properly. - Observation on 06/04/19 at 10:59 a.m. showed two certified nursing assistant (CNAs) (#9 and #10) placed a gait belt around Resident #14's waist and assisted her to transfer from her chair to bed. The CNAs (#9 and #10) held the gait belt with one hand and lifted under the resident's arm axilla with the other hand. The resident did not fully bear weight, and her knees bent to an almost 90 degree angle. - Observation on 06/05/19 at 9:55 a.m. showed two CNAs (#3 and #4) transferred Resident #3 from the wheelchair to bed with assist of two and a gait belt. CNA (#4) failed to properly use the gait belt during transfer and lifted Resident #3 under her right arm pit. - Observation on 06/05/19 at 1:55 p.m. showed a CNA (#6) transferred Resident #15 from the wheelchair to the toilet with assist of one with a gait belt. Review of Resident #15's medical record occurred on all days of survey. The current care plan stated, . Transfer with two staff assist with gait belt . During an interview on 06/06/19 at 9:05 a.m., a managerial nurse (#5) stated, if the resident requires assistance from two staff members, he expected one staff member to stand on each side of the resident with one hand on the back of the gait belt and one hand on the front of the gait belt. TOILETING ASSISTANCE 2. Based on information received from the complainants, record review, review of a professional reference, the facility failed to provide adequate supervision/assistance for 2 of 2 sampled residents (Resident #11 and #14) and 1 discharged resident (Resident #17) who fell while attempting to self-transfer to the bathroom. Failure to provide adequate supervision/assistance resulted in residents experiencing preventable falls with/without injury. Findings include: Information provided by the complainants indicated nursing staff failed to provide adequate supervision/assistance resulted in residents' attempts to self-tranfer to the bathroom. Berman, Snyder, and Frandsen's, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th edition, Pearson Education, Inc., New Jersey, page 651, stated, . Risk Factor and Preventative Measures for Falls: Urinary frequency or receiving diuretics, Weakness from disease process or therapy, Current medication regimen that includes sedatives, hypnotics, tranquilizers, narcotic [MEDICATION NAME], diuretics. Assist with voiding on a frequent and scheduled basis. Findings include: - Review of Resident #11's medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t (related to) Disease process (dementia), functional incontinence, [MEDICAL CONDITIONS] . Provide assistance with toileting every two hours at minimum. At risk for falls due to: history of falls, impaired balance/poor coordination. Interventions: Increased toileting during nighttime hours (every 2-3 hours). Progress notes identified the following: * 05/02/19 at 6:30 p.m., . Light sounding . Lying on back next to foot of his bed .Was sitting in recliner prior . Incontinent of urine . * 05/04/19 at 6:41 a.m., . Kneeling on floor by bed . Incontinent of urine . * 05/30/19 at 9:57 a.m., . Lying on floor in front of recliner . Large loose incontinent BM (bowel movement) . * 05/31/19 at 12:46 p.m., . Found on floor next to bathroom . Had incontinent BM . Toileting documentation identified staff assisted Resident #11 as follows: * 05/02/19 at 2:42 a.m. and 9:56 p.m. * 05/04/19 at 4:05 a.m., 7:51 a.m., and 8:45 a.m. * 05/30/19 at 2:11 a.m., 10:26 a.m., and 9:47 p.m. * 05/31/19 at 2:13 a.m., 10:24 a.m., and 9:02 p.m. - Review of Resident #14's medical record occurred on all days of survey. The current care plan identified, . Urinary incontinence r/t: disease process dementia, impaired mobility . provide incontinent care as needed . At risk for falls due to: impaired balance/poor coordination . anticipate resident needs; assess comfortable for positioning in bed; reposition and provide incontinent cares at routine times . Progress notes identified the following: * 03/17/19 12:34 a.m., . found on the floor . lying on her back with her lower extremities under the bed . call light . sounding when staff arrived . found incontinent of bladder and incontinent of a small BM . * 04/07/19 at 10:34 p.m., . resident was sitting on the floor by her bed . incontinent of bowel . Toileting documentation identified staff assisted Resident #11 as follows: * 04/07/19 at 9:27 a.m. * 03/17/19 at 12:48 a.m., 9:53 a.m., and 8:57 p.m. - Review of Resident #17's medical record occurred on all days of survey. The record identified [DIAGNOSES REDACTED]. The care plan identified, . requires assistance related to physical limitations, visual impairment . CNA (certified nursing assistant) to assist to toilet prior to and following meals. Offer toileting on last rounds for night shift. Progress notes identified the following: * 01/12/19 at 9:19 p.m., Resident is on follow up for: Un witnessed fall in her bathroom. Resident is unable to transfer self back and fort (sic) (to) the bathroom. Resident educated to wait for assistance after activating call light, can't transfer self. Failure to offer residents supervision/assistance with toileting on a more frequent basis may have resulted in Resident #11, #14, and #17 experiencing preventable falls. Refer to F585 and F690. |
2020-09-01 |