| 12711 |
COLONIAL MANOR OF RANDOLPH |
285183 |
P O BOX 67, 811 SOUTH MAIN STREET |
RANDOLPH |
NE |
68771 |
2010-09-02 |
279 |
E |
|
|
DGBS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record reviews and staff interview; the facility failed to develop comprehensive care plans that addressed individual needs of residents and specific interventions for 5 of 10 residents reviewed (Residents 2, 12, 23, 24 and 35). Facility census was 35. Findings are: A. Review of Resident 24 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/17/10 indicated [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of a Change in Condition Report-Post Falls/Trauma form dated 11/13/09 revealed Resident 24 fell while ambulating to the dining room with walker. Documentation on the same form indicated the resident would continue to receive restorative therapy, gait would be monitored, and resident would be reminded to request assistance if feeling weak. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of the Resident Care Plan with a team conference date of 11/25/09 indicated falls were not addressed on the care plan and there were no interventions in place to prevent falls. Review of Change in Condition Report-Post Falls/Trauma forms dated 12/23/09 and 1/5/10 revealed Resident 24 fell in room and while ambulating in the hallway respectively. Documentation on the same forms indicated the resident would be reminded to go slowly when first getting up and when walking. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was not at high risk for falls. Review of a Change in Condition Report-Post Falls/Trauma form dated 3/10/10 at 5:15 AM revealed Resident 24 was found on the floor next to bed and a body alarm was applied to be used at all times. Documentation on the same form indicated the resident " does not remember to call for assist " . Review of a Change in Condition Report-Post Falls/Trauma form dated 3/10/10 at 11:30 PM revealed Resident 24 was found on the floor and body alarm was sounding. Documentation on the same form indicated a " Hi-low bed " was placed in the resident ' s room, the bed was to be placed in the low position when Resident 24 was in bed at night, and the body alarm was to continue to be used at all times. Review of a Change in Condition Report-Post Falls/Trauma form dated 3/17/10 at 7:30 PM revealed Resident 24 was found on the floor after sliding from the wheelchair. Documentation on the same form indicated staff would talk to the Occupational Therapist regarding a different cushion in the wheelchair to prevent sliding, and staff would make sure all needs were met before leaving the resident ' s room. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of Change in Condition Report-Post Falls/Trauma forms dated 4/6/10 and 5/20/10 revealed Resident 24 was found on the floor after falling from recliner chair. Documentation on the same forms indicated Resident 24 was reminded to use call light to call for assistance, and staff were to visit with Physical Therapist and family regarding an electric lift chair for resident. Documentation further indicated Resident 24 frequently removed the body alarm. Review of the Fall Risk assessment dated [DATE] revealed Resident 24 was at high risk for falls. Review of Change in Condition Report-Post Falls/Trauma forms dated 6/11/10 and 7/8/10 revealed Resident 24 was found on the floor after falling from recliner chair. Documentation on the same forms indicated Resident 24 was reminded to use call light to call for assistance, and staff would initiate a chair alarm to be used in the seat of the recliner due to the resident unhooking the body alarm. Review of a Change in Condition Report-Post Falls/Trauma form dated 8/20/10 revealed Resident 24 lost balance and fell while ambulating with staff from the bathroom. Documentation on the same form indicated staff were to use gait belt (a belt which is placed around a resident's waist that provides a secure and safe hand hold for caregivers when transferring residents) when ambulating, and a " hi rise walker " (an ambulation device that provides a chest level platform that the resident is able to lean on for further support while walking) in the evening when resident is more tired. Review of the Resident Care Plan dated 6/10/10 indicated falls were not addressed on the care plan and there were no interventions in place to prevent falls. B. Review of Resident 23 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The same form revealed Resident 24 received this medication 21 times in 5/10 for symptoms of anxiety, restlessness and crying. Review of the Resident Care Plan with a team conference date of 5/6/10 revealed Resident 23 needed medications to control mood and behaviors, including ABH gel. However, there were no alternative interventions specified in the care plan for staff to attempt to control Resident 23 ' s behaviors other than use of psychoactive medication. Review of the MAR ' s revealed Resident 23 received ABH gel 57 times in 6/10, 58 times in 7/10 and 50 times in 8/10 for symptoms of restlessness, anxiety, agitation, combativeness, hitting, pacing, swearing and crying. C. Review of Resident 35 ' s MDS dated [DATE] indicated [DIAGNOSES REDACTED]. Review of the current Resident Care Plan with a team conference date of 1/14/09 indicated pain was not address as a problem for Resident 35 and there were no interventions in place to control symptoms of pain. Review of a hospital Discharge Summary dated 6/25/10 revealed the resident was hospitalized [DATE] through 6/14/10 for an acute L2-L3 (lumbar vertebrae of the spine) fracture, [MEDICAL CONDITION] joint disease, chronic lumbar pain and [MEDICAL CONDITION]. Review of the MDS dated [DATE] indicated Resident 35 experienced daily pain in the back, and at times the pain was horrible or excrutiating. Review of the MAR indicated [REDACTED]. D. Review of Resident 2 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/7/10 revealed [DIAGNOSES REDACTED]. The 7/7/10 MDS indicated the resident had short term and long term memory problems with severely impaired cognitive skills for daily decision making. This MDS further indicated Resident 2 had behaviors of wandering (movement with no rational purpose, seemingly oblivious to needs or safety). Review of Resident 2 ' s Elopement (when a cognitively impaired resident leaves the facility unattended and without staff knowledge) assessment dated [DATE] revealed the resident was at risk for elopement. Review of the Resident Care Plan dated 7/15/10 revealed Resident 2 was to wear a wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). Review of Interdisciplinary Progress Notes dated 8/8/10 at 10:30 AM indicated Resident 2 exited the building unattended and without staff knowledge. Review of Resident 2 ' s current Resident Care Plan (dated 7/15/10) revealed no additional interventions for the prevention of elopement. E. Review of Resident 12 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/16/09 revealed [DIAGNOSES REDACTED]. MDSs dated 9/16/09, 12/8/09, 3/25/10 and 8/18/10 indicated the resident had no short term or long term memory problems and displayed behaviors of making negative statements. Review of the Resident Care Plan revealed a goal was established 9/18/09 for Resident 12 to " ...make 3 or less negative comments a week for the next 90 days. " Review of Interdisciplinary Progress Notes (IPN ' s) dated 2/6/10 for the 7:00 AM to 3:00 PM shift revealed documentation that Resident 12 made " rude comments " to other residents and visitors. Review of IPN ' s dated 2/9/10 at 1:00 PM indicated Resident 12 was seen by the physician " ...for behaviors ... " Review of physician's order [REDACTED]. Review of the current Resident Care Plan dated 8/26/10 revealed Resident 12 ' s [MEDICATION NAME] was not identified and no additional interventions had been developed regarding the resident ' s " rude behaviors " . The Director of Nurses verified during interview on 9/2/10 from 2:10 PM until 2:50 PM the Resident Care Plan for Resident 12 did not contain interventions specific to the identified behaviors. The DON stated the facility was " behind " on completing Resident Care Plans. |
2014-04-01 |