cms_NE: 11251
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11251 | AINSWORTH CARE CENTER, LLC | 285142 | 143 NORTH FULLERTON STREET | AINSWORTH | NE | 69210 | 2013-11-13 | 280 | E | 0 | 1 | 320W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews; the facility failed to review and revise Care Plans related to fall interventions for Residents 27, 15 and 23. In addition, Resident 15's Care Plan was not revised for prevention and treatment of [REDACTED]. A. Review of Resident 15's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for Care Planning) dated 10/16/13 indicated [DIAGNOSES REDACTED]. The assessment indicated Resident 15 was at risk for pressure sore development and had a history of [REDACTED]. The MDS further indicated Resident 15 was at risk for falls and the resident had sustained 1 fall without injury and 2 falls with injury since the previous assessment. Review of Care Plan dated 11/1/13 revealed Resident 15 had a history of [REDACTED]. Interventions included the following: -9/25/12 Tab alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) on at all times -10/17/12 pressure pad alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) on at all times -12/13/12 may put mattress on floor for resident to sleep on per resident's request -7/25/13 may use tilt-n-space wheelchair -10/30/13 ensure Tabs alarm cord length is adjusted to proper length -may use sit-to-stand mechanical lift for transfers -bolsters to resident's bed and fall mat on floor next to bed -keep bed in lowest position with brakes locked -observe resident frequently and place in supervised areas when out of bed In addition Resident 15's Care Plan indicated the resident was at risk for pressure sores. Interventions included the following: -keep heels elevated. -keep feet and heels moisturized -keep heels protected as resident allows and remind resident that rubbing heels on the chair aggravates the wound on heel. -6/15/13 to keep heels on "heels up" device to prevent pressure Review of Resident 15's Event Reports revealed the following: -8/22/13 at 4:30 PM, the resident was found on the floor by the bathroom door. Wheelchair was behind the resident, resident noted to have 3 skin tears to right hand/forearm. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. -9/18/13 at 11:40 AM, the resident was found lying on the floor in front of the wheelchair with no injuries evident. There was no documentation of any causal factors identified or of any new interventions to protect resident from further falls. Review of Resident 15's Fall Risk assessment dated [DATE] revealed the resident was identified at high risk for falls. Review of Resident 15's Braden Scale For Predicting Pressure Sore Risk dated 10/15/13 indicated a total score of 14 (score of 13-14 indicated moderate risk). Review of Resident 15's Event Report dated 10/29/13 revealed at 4:05 PM, the resident slid out of wheelchair onto the Dining Room floor. Tabs alarm was in place but was not activated. Staff shortened the cord of the alarm to ensure prompt activation of the alarm; however no casual factors for the fall were documented. Review of "Event Report" dated 11/1/13 revealed a Hospice Nurse had informed facility staff of an intact blister to Resident 15's left lateral heel. This report indicated the area surrounding the blister was intact, slightly red and had a "mushy" feeling. The report further identified Resident 15 refused to leave heel protectors on feet and had requested to wear shoes. The resident's Care Plan did not reflect the resident's non-compliance with use of heel protectors. During an interview on 11/7/13 from 11:00 to 11:15 AM, the Director of Nursing (DON) confirmed staff was expected to review interventions after all falls and that staff were to revise and implement new interventions to prevent potential injury from further falls. During an interview on 11/6/13 from 2:47 PM to 2:55 PM, Nursing Assistant (NA)-A verified Resident 15 was to wear heel/ankle protectors at all times but indicated the resident was not always compliant with leaving them in place. NA-A stated, "The resident used to have heel protectors in the room but I don ' t know where they are or what happened to them." Review of the Registered Dietician's progress notes dated 11/6/13 indicated the resident was receiving adequate nutrition to promote healing but the resident chose to consume less than adequate nutrition. Furthermore, healing was not expected unless friction could be removed. No new interventions were identified on the Resident's Care Plan Review of fax from the physician dated 11/7/13 (6 days after the areas to the resident's left heel were identified) revealed an order for [REDACTED]. Review of "Event Report" dated 11/7/13 revealed facility staff had identified a new reddened area to Resident 15's medial left heel. The area measured 1 cm x 2.5 cm and was not opened at the time. There was no documentation on the resident's Care Plan related to this area. During an interview with the Director of Nursing (DON) on 11/7/13 from 11:00 AM to 11:15 AM, the DON verified facility staff should have updated and revised Resident 15's Care Plan to reflect new areas of breakdown to the left heel and recommendations from the Registered Dietician and the physician. B. Review of Resident 23's MDS dated [DATE] revealed the following: - Resident 23 scored 7 on the Brief Interview for the Mental Status (an assessment used to determine mental ability). A score of 0-7 indicated the resident's cognition was severely impaired. - Resident 23 required extensive assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. Review of Resident 23's Care Plan dated 1/13/13 revealed a problem of "Risk for falls related to (R/T) unsteadiness" , a goal of "Resident will remain free of falls " and the following Approaches: - "Encourage/Remind resident to ask for assistance before transferring (gender) to the bathroom" . - "Encourage and praise resident for asking for assistance" . - "Tabs at all times" . - "Wheelchair (W/C) for ambulation at all times with exception of full weight walker (FWW) walker w/stand by staff assist per physical therapy (PT) orders" . - "Staff is to make resident's bed daily" . - "Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair" . - "Assure the floor is free of glare, liquids, foreign objects" . - "Encourage resident to assume a standing position slowly" . - "Encourage resident to use environmental devices: (e.g., handrails, grab bars, etc.) Walker can be used with stand by assist only" . - "Keep bed in lowest position with brakes locked" . - "Keep call light in reach" . - "Keep environment free of clutter" . - "Keep personal items and frequently used items within reach" . - "Leave night light on in room" . - "Provide proper, well-maintained footwear. Do not allow resident to walk in stocking feet" . - "Resident (res.) Will ask staff for help when she wants to hang clothes in closet" . Review of Resident 23's Care Plan dated 8/21/13 revealed a problem of " Resident non-compliant w/transfers and ambulation. Walking without the recommended assistance. Benefits versus Risk have been explained to resident and power of attorney (POA) and form signed" , a goal of "Resident will ask for assistance for transfers and ambulation" and the following Approaches: - "Frequent resident contact" . - "Remind resident of the benefits vs. risk" . - "Remind resident to use (gender) call light at all times" . Review of Resident 23's Care Plan dated 3/9/11 revealed a problem of "Resident is limited in mobility and requires the use of a wheel chair. Can ambulate w/front wheel walker with stand by assist only" , a goal of " ...will safely ambulate thru out the facility with the use of wheeled walker (w/w)" and the following Approaches: - "Teach resident safety measures. Instructed res to use call light to kill bugs" . - "Adapt environment to maximize (Resident 23) safety and independence: grab bars and clear pathways" . - "Instruct (Resident 23) in proper technique" . - "Provide oversight for ambulation" . - "Teach (Resident 23) safety measures" . Observations of Resident 23 on 11/6/13 from 12:51 PM until 2:57 PM and on 11/7/13 from 6:38 AM until 8:08 AM revealed Resident 23 to have a tabs and sensor alarm attached to the back of her wheelchair. Observations of Resident 23 on 11/7/13 at 9:11 AM revealed RN-E exit Resident 23's bathroom, shutting the door but not latching it. Resident 23's wheelchair was not observed to be in the room. At 9:20 AM Resident 23 was heard yelling for help 3 times before NA-H entered the room to assist Resident 23. During an interview with NA-H on 11/7/13 at 10:21 AM it was confirmed Resident 23 was left unsupervised in the bathroom. NA-H confirmed Resident 23's wheelchair was in the bathroom with the resident and the resident ' s tabs alarm had been removed from the wheelchair, attached to the resident and left attached to a handrail in the bathroom. During an interview with DON and Administrator on 11/7/13 at 11:28 AM it was revealed residents who have tabs alarms not be left in the bathroom unattended. Observations of Resident 23 on 11/12/2013 from 9:30 AM until 2:48 PM and 11/13/2013 at 7:14 AM revealed Resident 23 to have a tabs and sensor alarm attached to the back of resident's wheelchair. Review of Resident 23's Care Plan revealed the approaches of a sensor alarm and not leaving the resident unattended in the restroom were not identified. C. Review of Resident 27's Care Plan dated 11/29/12 indicated the resident was at risk for falls related to unsteady gait, poor vision and cognitive deficits. Interventions included assistance with ambulation as needed and keeping the resident's bed in the lowest position. Review of Resident 27's Care Plan dated 1/18/13 indicated the resident was at risk for falls due to decreased safety awareness and unsteady gait. Additional interventions included to assure the floor was free of glare, liquids and foreign objects, involve the resident in meaningful activities, and leave a night light or room light on during the night. An additional intervention dated 4/29/13 was to monitor seating at activities. Review of an Event Report dated 6/26/13 at 4:20 PM indicated Resident 27 fell in the dining room. The report indicated the resident was standing independently; the resident's legs "twisted" as the resident turned, and the resident "tripped over right leg". The resident was transferred to the hospital for x-rays of the right hip. Review of a Progress Note dated 6/26/13 at 8:32 PM revealed Resident 27 had a [MEDICAL CONDITION] and was admitted to the hospital for a hip repair. Following Resident 27's fall with fracture, there was no documentation to indicate the resident's Care Plan was reviewed and revised to prevent the occurrence of further falls. | 2015-07-01 |