| 258 |
HIGHLAND PARK CARE CENTER |
285063 |
P O BOX 950, 1633 SWEETWATER |
ALLIANCE |
NE |
69301 |
2018-08-23 |
689 |
G |
0 |
1 |
EHQ211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b (3 and 4) Based on record reviews and interview, the facility failed to ensure that interventions were in place to prevent recurrent falls with injuries including a cervical fracture with ongoing pain and multiple abrasions with pain for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's care plan, goal date 8/20/18, revealed that the resident had a history and potential for falls related to a history of self transfers and self ambulation, confusion, impaired gait and balance, incontinence, antidepressant and diuretic medications, was unaware of safety needs, weakness, difficulty in walking, refusal of cares and physical and verbal aggression and agitation at times. Further review revealed a focus area, dated 8/20/18, which stated that the resident sustained [REDACTED]. Other focus areas included that the resident had cognitive impairment related to both short term and long term memory troubles and the resident required assistance with activities of daily living including transfers and toileting. Interventions listed on 7/4/18 revealed that the resident often self transfers, attempts to self ambulate and will often transfer self to the bathroom unassisted. Review of the Progress Notes revealed the following including: - 7/24/18 at 7:20 PM The staff found the resident on the floor at the foot of the bed. The resident stated was going to the bathroom. The resident complained of neck and shoulder pain and refused to go to the hospital for evaluation. The resident was educated on the use of the call light; - 7/25/18 at 1:35 PM The resident was sent to the to physician for evaluation of severe neck and shoulder pain almost unbearable; - 8/2/18 at 11:00 AM The resident was readmitted from the hospital with a [DIAGNOSES REDACTED].; - 8/4/18 at 1:08 PM The resident transferred self back to bed after breakfast and staff gave frequent reminders to call for assistance, the resident required extensive assistance of two staff for all transfers; 6:47 PM The resident attempted to self transfer multiple times this shift; - 8/10/18 at 1:23 PM The provider changed pain medications from routine to as needed; - 8/14/18 at 11:10 AM The resident was unable to use legs to stand up correctly in sit to stand lift, full body lift used at this time; - 8/17/18 at 1:27 PM The nurse witnessed the resident slip to the floor from the bed, the resident frequently attempts self transfers, no injuries noted; - 8/19/18 at 2:58 PM The resident was observed on the floor at 1:15 PM, the resident stated tried to get into bed, did not use the call light for assistance. The resident was transported to the emergency room via ambulance for evaluation. The resident returned to the facility at 6:45 PM and was treated for [REDACTED]. - 8/20/18 at 3:00 PM The resident is very confused and has been attempting to self transfer since 2:00 PM, 9:48 PM The resident had been attempting multiple times to self transfer this shift and is very confused and does not call for help; - 8/21/18 at 3:50 AM The resident was confused and was observed attempting to get up from bed, legs hanging out over the side of the bed. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident received [MEDICATION NAME] as needed for pain related to the cervical fracture 17 times from 8/11/1- 8/20/18 for pain rated 4-7 on the 0-10 pain scale with 0 indicating no pain and 10 the worst possible pain. The resident rated pain at 4 three times, 5 seven times, 6 three times and 7 four times. Review of the facility Fall Scene Investigation Reports revealed the following including: - 7/24/18 Initial Cause (s) of the fall? The resident did not call for assistance to go to the bathroom, knocked the wheelchair over, still did not call for help and then attempted to self transfer to the bathroom. Interventions to prevent future falls and verify implementation were encourage the use of the call light, educate on the use of the call light every time staff enters room and possible placement of a fall alarm. IDT (Interdisciplinary Team) interventions added to the care plan related to the event and observe to verify implementation: 1. Place anti -tip device on the wheelchair. 2. Have therapy evaluate transfer and determine if a trapeze would be appropriate for repositioning. 3. Offer to move the bed against the wall to open up room if the residents wants to self transfer. - 8/17/18 Initial cause(s) of the fall? Bed positioning and frequent attempts to self transfer. Interventions to prevent future falls and verify implementation: Care plan update, will not position the bed with both the head and foot elevated at the same time. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Staff to monitor bed position with each encounter and reposition bed if both foot and head elevated. 2. Remove turn sheet when not in use. - 8/19/18 Initial cause(s) of fall? Attempted to self transfer. Interventions put into place to prevent future falls and verify implementation: Provider ordered transport to the hospital emergency room per ambulance for assessment. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Schedule pain medications. 2. Document pain levels two times a day and report to provider if not adequate. Review of the Non -Pressure Skin Condition Records, dated 8/23/18, revealed the following skin injuries related to the fall on 8/19/18: - Digits to the left foot have multiple abrasions in various stages of healing and pain; - Digits to the right foot have abrasions to all digits except the fifth digit. Abrasions in various stated of healing and pain; - Entire left knee is reddened, several abrasions in various shapes and sizes inside the reddened area and pain; - Entire right knee is reddened with several abrasions in various sizes and shapes throughout the reddened area and pain. Interview with the Director of Nursing on 8/23/18 at 10:35 AM confirmed that the resident had a history of [REDACTED]. Further interview confirmed that fall interventions in place were not effective to prevent self transfers and subsequent falls with injuries. |
2020-09-01 |