| 4075 |
ROCK COUNTY HOSPITAL LONG TERM CARE |
285304 |
100 EAST SOUTH STREET |
BASSETT |
NE |
68714 |
2019-04-10 |
689 |
D |
0 |
1 |
8X4611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Numbers 175 NAC 12-006.09D7 Based on observations, record review and interview, the facility failed to assure a safe environment was provided for residents identified at risk for falls as fall prevention interventions were not implemented, revised and/or new interventions developed to prevent ongoing falls for 2 (Residents 3 and 18) of 4 sampled residents. Facility census was 22. Findings are: [NAME] Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/30/19 revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was moderately impaired, the resident required extensive staff assistance with toileting, transfers, dressing and personal hygiene and indicated the resident was frequently incontinent of bowel and bladder. The resident had 1 fall with a minor injury and 2 falls without any injury since the previous assessment. Review of a Nursing Progress Note dated 10/18/18 at 6:30 PM revealed the resident was heard calling for help. Upon entering the resident's room, the resident was found lying on the floor next to the resident's bed. When the resident was asked what had happened, the resident pointed to the heating unit on the wall and stated, I stepped up on that thing and it spun me around. review of the resident's medical record revealed [REDACTED]. Review of a Nursing Progress Note dated 12/3/18 at 8:10 PM revealed the resident was found seated on the floor of the resident's room, positioned next to the resident's trash receptacle. The resident had removed the resident's disposable, urinary incontinence brief and the brief was now located in the trash receptacle. While pointing to the trash receptacle, the resident indicated I was going to sit down on this, but it didn't hold me up. The resident was assisted to the bathroom. No injuries were noted. Review of a Falls Intervention Report dated 12/3/18 revealed the resident had been attempting to void in the trash receptacle and a new intervention was developed to remove the trash can from Resident 18's side of the room. Review of an Incident Report dated 1/4/19 at 7:50 PM revealed the resident had been found lying on the floor of the resident's room, next to the resident's bed. The resident reported tripping over something and then falling. The resident had a small reddened area to the side of the resident's head. Review of a Post-fall Evaluation Form dated 1/4/19 revealed the resident had been walking around the resident's room. The resident had been wearing shoes and was using the resident's walker. The form identified the resident had identified tripping on something. A new intervention was identified to clean up and to unclutter the resident's room. Review of Resident 18's current Care Plan with revision date 1/31/19 revealed the resident was at risk for falls due to unsteadiness and history of falls. The care plan identified the resident was forgetful and sometimes would forget the walker. The following interventions were identified: -remind the resident to use the walker as the resident is very forgetful; -assess the resident every 1-2 hours and as needed for incontinence and provide incontinence cares as needed; -keep call light within reach; -keep pathways clear; and -make sure shoes are in good condition with non-skid soles. Review of an Incident Report dated 3/9/19 at 4:05 PM revealed the resident was found on the floor of the resident's room, lying on the resident's left side. The resident's walker was located across the room from the resident and was not within the resident's reach. The report further indicated the resident was assisted to the bathroom and the resident's walker was given to the resident. Staff provided the resident reminders to keep the resident's walker within reach. In addition, a Physical Therapy (PT) consult was identified. Observations of Resident 18's room on 4/8/19, 4/9/19 and on 4/10/19 revealed the resident was in a semi-private room and the following was identified: -to the immediate right of the head of the resident's bed was a recliner. A floor lamp was positioned in the corner behind the resident's recliner; -a bedside table was positioned on the opposite side of this recliner and next to the wall; -a heating unit was attached to the wall to the right of the bedside table; -a trash receptacle was located underneath of the bedside table and next to the heating unit; and -on the wall opposite to the foot of the resident's bed there was a television stand with a television positioned on top, a table which contained 2 quilts and an additional trash receptacle. During an interview on 4/11/19 at 1:51 PM, the Director of Nursing (DON) confirmed the following regarding Resident 18: -the resident was at high risk for falls; -an investigation was to be completed after each fall and causal factors were to be identified; -based on the outcome of this investigation, a new intervention was to be developed or current interventions were to be revised; and -due to repeated falls in the resident's room, the resident's room was to have less clutter and there was to be no trash receptacles on Resident 18's side of the room. B. Review of Resident 3's MDS dated [DATE] included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; -extensive assistance with bed mobility, transfers and toilet use; and -no recent falls. Review of Resident 3's current Care Plan dated 2/4/19 indicated a history of falls and frequently forget my limits as I sometimes suddenly try to get up on my own. Nursing interventions included the following: -keep pathways clear and assure non-skid soles on shoes, good lighting in room and a night light in the bathroom; -keep call light near resident and remind of it's location; -check every 1 to 2 hours and as needed to see if needs anything such as bathroom, fresh water or food; -keep bed in low position and red mat (floor mat) on the floor beside it; and -may use Tabs alarm in chairs to alert staff of attempts to get up from the chair. Review of Progress Notes on 1/23/19 at 6:43 PM indicated Resident 3 was found on the floor in room with the wheelchair at the resident's feet. The resident complained of pain in the left buttock and had a swollen area on the left side of head. The Primary Care Provider (PCP) recommended continued monitoring and reporting of any changes in condition. Review of the Fall Investigation dated 1/23/19 at 7:10 PM revealed Resident 32 stated was sitting in wheelchair in room and reached for the bed. The wheelchair bumped the floor mat that was laying on the floor and the resident fell from the wheelchair. Causal factors related to the fall were not identified, and there was no evidence new interventions were implemented for the prevention of future falls. Review of Progress Notes on 2/4/19 at 4:35 PM indicated Resident 3 was found on the red mat that was on the floor of room beside the recliner. No injury was noted. The resident was toileted approximately 1 hour prior to the fall. Resident 3 reported sliding out of the chair and onto the footrest, and then onto the red mat. Review of the Fall Investigation dated 2/4/19 at 4:49 PM revealed the call light, water and belongings were within reach, the red mat was in front of the recliner and shoes were on. Resident 3 was checked on every 15 minutes. Causal factors related to the fall were not identified, and there was no evidence new interventions were implemented for the prevention of future falls. |
2020-09-01 |