| 11105 |
GOLDEN LIVINGCENTER - SORENSEN |
285107 |
4809 REDMAN AVENUE |
OMAHA |
NE |
68104 |
2012-01-05 |
309 |
K |
1 |
1 |
9QU611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09 Based on record review and interview; the facility staff failed to assess 5 residents ( Resident 1, 7, 11, 13, and 27) of 27 sampled and 7 non-sampled residents who had fallen, on an ongoing basis to identify potential changes in condition. The facility staff identified a census of 61. Findings are: A. Record review of the facility Neurological Check Policy and Procedure dated ,[DATE] revealed the following: -It is the policy of GLC (Golden Living Center) Sorensen to perform neurological checks when the following occurs: -MD orders the neuro (neurological) checks. -Change in mental status. -Residents sustains an un-witnessed fall, is unable to state whether he/she hit their head and it is not clear that the resident did not hit their head. -1. Check every 15 minutes x 4 for 1 hour. -2. Check every 30 minutes x 2 for 1 hour. -3. Check every hour x 4 hours. -4. Then check every 8 for 72 hours. Record review of a Admission Record dated [DATE] revealed Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Resuscitation Orders sheet dated [DATE], revealed Resident 27 had documentation for "no CPR". Record review of Resident 27's Minimum Data Set (A federally mandated comprehensive assessment tool used for care planning) dated and signed on [DATE] revealed the facility staff assessed the following about the resident: -Resident 27 had short and long term memory problems. -Decision making was severely impaired. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Balance during transitions and walking was assessed as " not steady, only able to stabilize with human assistance". -Frequently incontinent of bowel, bladder and having falls since admission. Additional [DIAGNOSES REDACTED]. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was "... found on the floor in mdr (main dining room)... Slid out of w/c (wheelchair) because of improper positioning". Record review of a Change in Condition Report (COCR) -Post Fall/Trauma report dated [DATE] revealed Resident 27 had fallen in the MDR. The report contained information Resident 27 had impaired safety awareness/judgement/unaware of position. The COCR contained an area to be checked if the neuro checks were completed. The neuro section was not marked as being completed at the time of the fall. Further review of Resident 27's Progress notes did not contain evidence that Resident 27 had neuro checks assessments completed after the fall. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was "... found in MDR on floor, other resident reported res (resident) slid out of chair... Red abrasion notes to back of head quarter size...". Resident 27's medical record did not contain evidence neuro assessments had been completed after the fall with the resulting abrasion to the back of the head. Record review of Resident 27's Progress Notes dated [DATE] revealed Resident 27 was found on the floor next to the wheelchair. According to the progress note dated [DATE], Resident 27 was assisted into the wheelchair, taken to (gender) room and assisted into bed. There was not any evidence that neurological assessment had been completed for Resident 27. The progress note contained information that Resident 27 had been found without a pulse,respirations and emesis (vomit) of brownish coffee color. Resident 27's physician was informed and pronounced that Resident 27 had expired. Interview with Resident 12 revealed the following: -Resident 12 was Resident 27's roomate at the time Resident 27 died . -After Resident 27 was put to bed on [DATE], Resident 12 heard different kinds of noises such as gurgling coming from Resident 27's side of the room. -Resident 12 turned on the call light and nobody answered the call light. -Residednt 12 started to yell for help and after about 30 minuites a staff responded. On [DATE] at 1:35 PM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported (gender) was informed that Resident 27 was on the floor. According to LPN B, LPN B entered the MDR were Registered Nurse (RN) C was in attendance of Resident 27. According to LPN B, LPN B checked to evaluate if Resident 27 had any injuries. LPN B reported completing the neuro check as part of the "assessment". LPN B confirmed Resident 27's record did not contain evidence of the neuro checks being completed. Interview on [DATE] at 2:30 PM, Nursing Consultant (NC) A confirmed that neuro assessments are to be completed on any resident who had un-witnessed falls. On [DATE] at 2:40 PM a follow up interview was conducted with NC A. During the interview NC A stated " no neuro checks had been completed" for Resident 27's un-witnessed falls. An interview was conducted on [DATE] at 2:43 PM with RN C. During the interview, RN C reported that (gender) was returning from break when responding to Resident 27 being found on the floor. According to RN C, another resident was attempting to help Resident 27 up from the floor. RN C reported intervening. RN C reported that (gender) was not sure if Resident 27 had hit (gender) head. RN C reported checking for bumps. When asked if neuro assessment had been completed for Resident 27, RN C stated "no". According to RN C, Resident 27 did not have any injuries and was taken to (gender) room. RN C reported that LPN B was instructed to complete the neuro checks. On [DATE] at 6:20 AM a follow up interview was conducted with LPN B. During the interview when asked if LPN B knew the facility policy and procedure for neuro checks, LPN B stated "no". When asked if LPN B knew what the standard in the community for neuro checks were, LPN B stated "no". When asked how long neuro checks were to be completed for a resident, LPN B stated "I think every 15 minutes for 24 hours." When asked if this was completed for Resident 27, LPN B stated "no". An interview with the Director of Nursing (DON) was completed on [DATE] at 8:20 AM. During the interview, the DON confirmed that neuro checks assessments had not been completed for Resident 27 after the falls noted on [DATE], [DATE] and [DATE]. During the interview the DON confirmed that ongoing assessments of the falls for Resident 27 had not been completed. the DON stated "yes" when asked if Resident 27 should have had completed ongoing assessments after the falls. On [DATE] at 10:45 AM an interview was conducted with NC A. During the interview, NC A reported there were "inconsistency with what staff believe the policy was for or how often to do neurochecks". An interview with the DON on [DATE] at 11:00 AM. The DON reported the policy had not been established for neurochecks until yesterday ([DATE]). When asked what the expectation was for completing neurochecks were prior to [DATE], the DON stated "We used the rule of 4". The DON reported that the rule of 4 wasn't written down or was there a policy. When asked what the expectations were for completing the neurocheck assessments, the DON stated" would expect neurochecks for any unwitnessed falls or of hitting of head". According to the rule of 4 for neuro checks would be the following: -Neurochecks every 15 miniutes x's 4. -Neurochecks every ,[DATE] hour x's 4. -Neurochecks every hour x's 4. -neurochecks every 8 hours x's 4. B. Record review of an Admission Record sheet dated [DATE] revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's MDS signed and dated [DATE] revealed the facility staff assessed the following about the resident. -Resident 1 had short and long term memory problems. -Severely impaired decision making. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Frequently incontinent of bladder and always incontinent of bowel. -No fall history was identified for Resident 1. Record review of Resident 1's Progress Notes dated [DATE] revealed Resident 1 "...had fell out of bed during this shift". Resident 1's record did not contain evidence that a neuro assessment had been completed or that an ongoing assessment of Resident 1's neurological status had been conducted. Record review of a Verification of Investigation sheet dated [DATE] for the occurrence dated [DATE] at 9:10 AM revealed Resident 1 had been seen on the floor by a Therapist. According to the information in the investigative report, the DON assessed the resident and did not identify any injuries. According to the investigation report, Resident 1 was identified with swelling on the right side of the face at a 11:00 PM on [DATE]. Resident 1 was sent to the hospital and returned with a fracture to the right periorbital area ( right eye area). Record review of Resident 1's Progress notes dated [DATE] revealed Resident 1 "rolled out of bed". Resident 1's medical record did not contain evidence that a neuro assessment had been completed or that an ongoing neuro assessment was conducted. Record review of Resident 1's Progress notes dated [DATE] revealed a late entry for [DATE] of Resident 1 being found on the floor "around 7:15 AM with a bruise to the left side of Resident 1's head. Record review of a Neurological Flow sheet revealed 2, 15 minutes checks had been completed with documentation identifying that Resident 1 was in therapy from 8:00 AM through 9:30 AM. There was not evidence the neuro assessment had been completed at those times. An interview was conducted on [DATE] with NC A. During the interview, NC A confirmed neuro assessments had not been completed for the incidents on [DATE] and [DATE] and was not completed for the incident on [DATE]. When asked if the neuro assessments should have been completed, NC A stated "yes". C. Record review of Resident 7's Admission Record dated [DATE] revealed an admitted [DATE]. Resident 7's History and Physical dated [DATE] revealed a [DIAGNOSES REDACTED]. of abnormal movements overall and moderate incapacitation due to abnormal movements. Observation on [DATE] at 12:02 PM revealed Resident 7 seated in a wheelchair and exhibited upper and lower extremity and trunk involuntary movements while in a wheelchair in the dining area of the facility. Record review of Resident 7's Nurses Note dated [DATE] revealed a note that read " *late entry for [DATE] ,[DATE] shift.*" The nurses note late entry revealed that Resident 7 had been found on the floor at 7:15 AM and that Resident 7 stated that the fall had occurred while trying to go to the bathroom. The nurses note identified that Resident 7 had a laceration above the left eye and complained of a headache. The nurses note indicated that crani checks (a neurological assessment used to evaluate the condition of a resident after a fall with a head injury) were documented on a crani check sheet. Record review of a Neurological Assessment record dated [DATE] for Resident 7 revealed that neurological assessments were started at 7:30 AM on [DATE] and continued every 15 minutes times 2 hours, then every 30 minutes times 2 hours, then hourly times 2 hours. There was no further documentation present in Resident 7's record of neurological assessment performed after 1:30 PM , 6 hours after Resident 7's fall, on the day of Resident 7's fall with a head injury. Interview on [DATE] at 10:45 AM with NC A confirmed that neurological checks for Resident 7 were not performed according to facility policy and that there was no documentation of neurological assessment performed for Resident 7 after 1:30 PM on the day of the fall. D. Based on Resident 13's face sheet, Resident 13 was admitted to the facility on [DATE]. Based on Resident 13's MDS dated [DATE], Resident 13 had the following Diagnoses: [REDACTED]. Review of the Facility Incident Log revealed Resident 13 fell out of bed on [DATE]. Review of the Change of Condition Report states the resident fell out of bed at 23:22 (11:23 PM) . Record review of Resident 13's Nurses Notes did not indicate Resident 13 fell . There is no entry at the time of the fall or no entry of what assessments or interventions were conducted in Resident 13's record. In an interview on [DATE] at 10:15 AM, RN Consultant-A confirmed none of these items were on the record. RN-Consultant-A stated that,based on the information in the record and what information is known about the incident, it is not believed that cranial checks were done or further ongoing assessment was done immediately following the fall. In an interview with LPN-C, it was confirmed that LPN-C was the nurse on duty when the fall occurred. LPN-C stated that Resident 13 was found on the side of the bed and had no apparent injuries so Resident 13 was returned to bed. E. Review of Resident 11's medical record revealed Resident 11 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 11's MDS dated [DATE] revealed Resident 11 required limited assist of 2 staff assistance for transfers. Review of the computerized Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor in (gender) room, next to bed". No documentation was found in the nursing notes to indicate if resident hit head. Review of Resident 11's Neurological assessment dated [DATE] revealed neurological checks were initiated after Resident 11 was found on the floor and were done every 15 minutes for 4 times, every 30 minutes for 4 times, 1 additional time, then no further checks were done as specified in the facility policy. Review of the computerized Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor in (gender) room next to bed, a few feet from w/c (wheelchair)". No documentation was found in the medical record to indicate if Resident 11 hit head. Review of Resident 11's Neurological assessment dated [DATE] revealed neurological checks were initiated after Resident 11 was found on the floor and were completed every 15 minutes for 4 times, every 30 minutes for 4 times, then 1 hour for 1 time but were not continued for the 72 hours per facility policy. Interview on [DATE] at 11:30 am with RN A confirmed that neurological checks were not completed per facility policy for Resident 11's falls on [DATE] and [DATE]. Review of Resident 11's Interdisciplinary Progress Notes (IPN) revealed on [DATE] Resident 11 was "observed on floor next to bed and w/c with legs straight out." No documentation was in the medical record to indicate if Resident 11 hit head. IPN states "crani checks" (another term for neurological checks) initiated. Review of Resident 11's medical record revealed no ongoing neurological assessments were completed. Interview with RN A revealed no ongoing neurological assessments were completed for Resident 11's fall on [DATE]. As outlined by the Administrator of the facility on [DATE] at 6:00 PM the facility initiated the following plan to address the immediacy of the situation. The facility will educate all nurses on fall management/clinical guidelines that were to include causal factors, cognitive status of residents, assessment of residents and the implementation of interventions. Nurses were to be educated on the facility Neurological assessment, in addition all staff were to be educated on call lights and responding to residents yelling out. All nurses were to be educated prior to allowing them to work. All falls were to be reviewed daily with the daily startup. Audits of all falls will be conducted x's 4 weeks, then 3 x's weekly x's 4 weeks and monthly thereafter. With the above interventions initiated, the scope and severity of the deficiency was lowered to an "E". |
2015-08-01 |