cms_NE: 23
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2018-03-15 | 689 | D | 1 | 0 | KRL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure reference: 175 NAC 12-00.09D7b Based on observation, interview, and record review, the facility failed to evaluate falls for potential causal factors and implement interventions to prevent reoccurrence for 2 (Residents 2 and 5) of 5 sampled residents. The facility had a total census of 231 residents. Findings are: [NAME] Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's care plan revealed a [DIAGNOSES REDACTED]. Observations on 3/15/18 at 8:43 AM revealed Resident 5 being assisted to transfer from recliner to wheelchair by Nurse Aide A with use of a gait belt and walker. A note attached to Resident 5's closet door reminded Resident 5 to use the call light. Resident 5's Care Plan included a problem dated of self care deficit/high risk for falls dated 1/9/18. The care plan listed the following interventions for falls: -Call light within reach. Check frequently and anticipate all needs. 15 minute safety checks or one to one supervision as needed for safety. -Resident 5 is at high risk for falls. Ensure oxygen tubing isn't a trip hazard. Assist of one for all mobility. -Fall 1/20/18 no injuries -Fall 1/25/18 no apparent injuries -Fall 2/8/18 no apparent injuries -Fall 2/21/18 no injuries noted -Fall 2/25/18 abrasion to right buttock A review of Fall Risk assessment dated [DATE] identified Resident 5 at a high risk for falling. A review of Resident 5's Nurses Notes revealed the following falls: -2/25/18 7:50 AM Resident noted to be in sitting position next chair with table partially tipped over. Resident 5 reported Resident 5 was going to get clothes. Resident had abrasion to lower buttock. Notes taped to Resident's closet to remind to ask for help. -2/21/18 9:15 PM Resident 5 observed sitting on floor in room on bottom. Resident 5 reported feet slipped out in front of Resident 5. No injuries noted. Resident encouraged to use call light. -2/8/18 7:30 AM Resident 5 slid out of recliner chair at 6:45 AM. No apparent injuries. -1/26/18 11:25 PM Resident 5 observed on the floor at 11:10 PM. Resident 5 had apparently got out of bed and slid. -1/20/18 1:45 AM Resident 5 sitting on floor next to chair. Resident 5 reported trying to get the cord that goes in my nose off the floor A review of falls questionnaire dated 1/20/18 for Resident 5 listed no recommendations for prevention of the fall. The falls questionnaires for Resident 5 dated 1/25/18, 2/8/18, and 2/25/18 all listed use call light as the recommendation for prevention of the fall. A review of Therapy Order Request Form for Resident 5 revealed order for physical and occupational therapy had been requested on 2/26/18. Order for physical and occupational therapy was signed on 3/9/18. In an interview on 3/15/19 at 12:16 PM, Physical Therapist C reported that an order for [REDACTED]. In an interview on 3/15/18 at 11:59 AM, Registered Nurse D reported the fall questionnaire is used to track falls and to monitor to ensure new interventions are put in place. Registered Nurse D reported that Registered Nurse D has not reviewed Resident 5's 2/2018 as Registered Nurse D just took over the unit. Registered Nurse D confirmed new interventions should have put in place for fall prevention. B. A review of Resident 2's Care Plan dated 3-21-17 revealed that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Fall Tracking Log revealed that the resident had 27 falls since 12-3-17. The falls occurred on 12-3-17, 12-9-17, 12-21-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-5-18, 1-31-18, 2-1-18, 3 falls on 2-6-18, 2-13-18, 2-14-18, 2 falls on 2-16-18, 2-18-18, 2-20-18, 2-24-18, 2 falls on 2-26-18, 2-27-18, 2-28-18, 3-2-18, and 2 falls on 3-4-18. A review of Resident 2's Nurses Notes dated 12-3-17 revealed that the resident had fallen in the bathroom and sustained a laceration to their forehead. The resident was sent to the emergency room where the resident received staples to close the laceration and was admitted to the hospital for observation. A review of Resident 2's Care Plan dated 3-21-17 revealed the following fall events were documented on the care plan: 12-9-17, 12-27-17, 12-30-17, 1-2-18, 1-3-18, 1-31-18, 2-12-18, 2-13-18, 2-14-18, 2-18-18, 2-20-18, 2-24-18, 2-26-18, 2-27-18, and 3-4-18. There were no new interventions put in place with the fall events. The fall events for 1-2-18 and 2-20-18 revealed that the resident continued on 15 minute checks. An interview conducted on 3-15-18 at 11:05 with Registered Nurse (RN) B revealed that the 15 minute checks for Resident 2 were not being used to prevent falls and that the checks were mostly for night time when the resident was sleeping. RN B reported that the nursing staff filled out fall questionnaires for each fall, but that RN B disposed of the questionnaires once they had processed the data. An interview conducted on 3-15-18 at 12:56 with RN B revealed that when a resident falls, the facility tracks the falls and interventions using the Care Plan. RN B reported that the Care Plan was read after each fall and the current interventions were reviewed to see what was in place at the time of the fall. The new interventions were then written on the care plan. RN B confirmed there were no new interventions on Resident 2's Care Plan for falls. | 2020-09-01 |