| 12651 |
HIGHLAND PARK CARE CENTER |
285063 |
P O BOX 950, 1633 SWEETWATER |
ALLIANCE |
NE |
69301 |
2011-04-11 |
280 |
D |
|
|
8W6H11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09C1c Based on record reviews and staff interviews; the facility failed to update the care plan for 1) care interventions following a fall with injury for 1 sampled resident (Resident 25); and 2) routine hypnotic use for 1 sampled resident (Resident 7). The facility census was 45 and the Stage 2 survey sample was 27 residents. Findings are: A. Review of the "Face Sheet" revealed that Resident 25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Interdisciplinary Progress Notes", dated 4/4/11, revealed that at, 7:00 AM, the resident was found sitting on the bathroom floor. Further review revealed that the resident complained of increased pain around the left ankle and the top of the foot. Swelling was noted at the ankles. The physician was notified and an x ray was ordered. Review of the x ray report of the left ankle, dated 4/4/11, revealed an irregularity at the tip of the medial malleolus which may relate to acute or chronic injury, smoothly marginated periosteal reaction of the lateral malleolus, and diffuse soft tissue swelling. Review of the "Telephone Orders", dated 4/5/11, revealed orders for no weight bearing at the left ankle for 1 week or so, keep the left ankle wrapped and in stabilizer, and elevate when not at meals. Review of the "Care Plan", goal date 4/21/11, revealed a problems including the following: - Potential for alteration in comfort, chronic pain related to [MEDICAL CONDITION] joint changes in hips and spine. Approaches included 4/4/11 - increased pain at the left ankle and foot with swelling, placed on no weight bearing status,and keep left leg wrapped; - Requires assist with activities of daily living related to weakness and short of breath. Approaches included - assist resident with transfers and ambulation with a gait belt and 1 assist. Further review revealed no approaches to include the use of a sit/stand mechanical lift for transfers, the use of the stabilizer boot, and instructions to keep the left leg elevated when not at meals. The care plan did not address the need to routinely check the circulation, motion, sensation, and swelling at the resident's left foot to monitor for potential complications. Interview on 4/11/11 at 3:30 PM with the DON (Director of Nursing) confirmed that the care plan should have been updated to reflect the changes in care approaches for the resident after the injury to the left foot. B. Review of Resident 7's chart revealed Resident 7 had been admitted to the hospital and re-admitted to the facility on [DATE]. physician's orders [REDACTED]. Review of Resident 7's "Care Plan" with goal and target dates through 6/2/11 revealed the care plan had not been revised to identify Resident 7's routine use of a hypnotic medication. The care plan did not include any approaches or interventions to monitor sleep patterns, assess the causes of [MEDICAL CONDITION], or identify other non-medicinal interventions to promote restful sleep. Interview with LPN (Licensed Practical Nurse)-L on 4/11/11 at 3:40 p.m. revealed LPN-L was the unit coordinator overseeing the clinical care of Resident 7. LPN-L verified Resident 7 had not been using a hypnotic medication prior to being hospitalized . LPN-L confirmed Resident 7 had begun the routine [MEDICATION NAME] upon return from the hospital on [DATE] and the resident's care plan had not been updated to identify this use and develop approaches to promote sleep. Interview with the DON on 4/11/11 at 4:00 p.m. verified the routine use of a hypnotic medication, used to promote sleep, had not been added to Resident 7's care plan. |
2014-04-01 |