| 4844 |
SIDNEY CARE AND REHABILITATION CENTER, LLC |
285113 |
1435 TOLEDO STREET |
SIDNEY |
NE |
69162 |
2018-03-06 |
689 |
H |
0 |
1 |
9WK311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, record reviews and interviews; the facility failed to ensure that 1) causal factors were identified, assessments were completed related to a dislocated shoulder and follow up interventions were in place to reduce the risk of recurrence for one current sampled resident (Resident 176), 2) a finger injury was identified, assessed and care provided for one current sampled resident (Resident 21) and 3) interventions were in place to prevent a fall with facial fractures for one current sampled resident (Resident 76). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/24/18 at 7:29 PM, revealed that the resident required one staff member assist with toileting. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requests the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. At that time, the resident denied pain at the left shoulder. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Final Impression: Headaches and reported shoulder dislocation; - Differential Diagnosis: [REDACTED]. - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. The dislocation may have occurred while trying to assist the patient off of the toilet. Review of the emergency room discharge handout Shoulder Dislocation included the following information: What causes a shoulder dislocation? - a fall on an outstretched arm, a hard pull on your arm, loose tissues around your shoulder joint that allow the joint to move more than it should. What are the signs and symptoms of a shoulder dislocation? - shoulder an arm pain that worsens with movement, redness and swelling of you injured shoulder, weakness, numbness or tingling in you injured shoulder and arm. How is a shoulder dislocation treated? - manual reduction where healthcare providers use their hands to move your dislocated arm back into place, you may need medications such as a muscle relaxer, sedative or anesthesia, - you may need a sling, splint or brace. Review of the care plan, initiated on 2/26/18, revealed that the resident required extensive assistance of two staff with bed mobility, transfer, dressing, toileting and personal hygiene. Interventions initiated on 2/27/18 included spouse indicates that the resident's left shoulder dislocates frequently and occurs with slight movements. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no assessment of the left shoulder injury on 2/24/18 including causal factors, intensity of the pain, that there was impaired circulation at the left arm or that the spouse reduced or placed the shoulder back into place. The DON confirmed that there was no documentation of the resident's condition, including shoulder pain until 2:59 PM. Further interview confirmed that the care plan was not updated with interventions to reduce the risk for recurrent dislocation of the left shoulder. B. Record review of Resident 21's Admission Record printed on 2/28/18 revealed the resident was initially admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Observation of Resident 21 on 2/27/18 at 11:43 a.m. revealed the resident's fifth little finger on the right hand was splinted and the splint was taped to the fourth and fifth fingers for mobility. Interview with Resident 21 on 2/27/18 at 11:43 a.m. revealed the resident could not recall how the finger was injured. Record review of Resident 21's Progress Notes revealed the following entries: - 2/25/18 at 1:50 p.m., RN (Registered Nurse)-G recorded: Family came to nurse's station with concern's the resident's pinky finger on the right hand was broken. this nurse went to assess and found the finger swollen and purple in color. When asked what happened, the resident said (Resident) sneaked out last night and shut it in the car door then said, I didn't tell anyone because (the resident) didn't want anyone to know (the resident) sneaked out. Resident given Tylenol 325 mg (milligrams) two (tabs) and ice placed on site. Will continue to monitor. - 2/25/18 2:07 p.m., RN-G recorded This nurse went to staff and inquired whether or not they knew of resident's injury to (the resident's) pinky. All my staff denied knowing of injury and denied it occurred on evening shift yesterday (2/24/18) (NA (Nurse Aide)-H) stated that night shift (NA-I) knew of the injury when day shift NA's (Nurse Aides) began working today (2-25-18). This nurse will discuss the injury with the night shift nurse when (the nurse) arrives. - 2/25/18 at 6:38 p.m. LPN (Licensed Practical Nurse)-J recorded the resident was assessed for bruising on 5th digit of the right hand with pain medication and ice as needed. LPN-J recorded the physician ordered for the resident to be taken to the emergency room for x-ray of the 5th digit of the right hand. - 2/25/18 at 9:46 p.m. LPN-J recorded the resident returned from the emergency room with a [DIAGNOSES REDACTED]. Orders were received for follow up with the physician in 1-2 weeks and to be seen every 1-2 weeks to check on compliance and complications. Further orders were for Tylenol 650 milligrams orally every 4-6 hours as needed. - 3/1/18- at 4:30 p.m. the Director of Nursing documented the resident's splint was removed for assessment after ice applied. Noted some swelling and bruising to the distal joint which the resident reported only hurts when I mess with it. Resident aware of injury and told the Director they called it a mallet finger. The resident was unable to recall how it happened. The splint was replaced and taped. Record review of documents from the emergency room , regarding Resident 21's injured finger, revealed the following: - Discharge Instructions revealed the resident came to the emergency roiagnom on [DATE] at 7:57 p.m. and was diagnosed with [REDACTED]. - An informational document was provided for What you need to know for a Jammed Finger. The document recorded A jammed finger is an injury to the tendon that straightens the tip of your finger. A piece of bone may be pulled away with your tendon. Your injury may take 4 to 8 weeks to heal. Record review of a facility investigation of Resident 21's finger injury incident completed on 3/1/18 revealed in the Outcome that LPN-J had cleaned the resident's fingernails during the morning of 2/25/18 around 4:15 a.m. and did not discover an injury. NA-I noticed bruising to the finger between 4:30 a.m. and 4:45 a.m. and reported the bruising to the oncoming day shift but not to the night nurse or the day nurse. The outcome of the investigation is inclusive (sic for inconclusive) as we can't determine a cause of the injury. The document recorded for preventative measures that administration that they discussed with NA-I the requirement to report any and all injuries to the charge nurse immediately to the supervising charge nurse. Interview with NA-E on 3/1/18 at 10:45 a.m. revealed NA-E recalled coming to work the morning of 2/25/18 and that NA-I reported Resident 21 sustained an injury to the right hand pinky finger. NA-E stated not reporting to the charge nurse as the day shift staff thought NA-I had already done so. Record review of Resident 21's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed a Quarterly MDS was completed on 1/29/18. The MDS recorded the resident received Extensive Assistance (Resident involved in activity, staff provide weight bearing support) for positioning in bed and transferring between surfaces such as bed to chair, toilet, or wheelchair. Interview with the Administrator and Corporate Nurse Consultant on 3/6/18 at 11:00 a.m. confirmed that during the night shift early morning on 2/25/18 the resident sustained [REDACTED]. Due to this, the injury was not assessed, physician notified, or treatment initiated until the family reported the incident on 2/25/18 at 1:50 p.m. and the resident was not seen in the emergency room until 7:57 p.m. on 2/25/18. C. Record Review of Resident 76's Admission Record printed on 2/28/18 revealed an Admision date to the facility on [DATE]. Observation on 02/27/18 at 9:30 a.m. revealed Resident 76 was sitting in their recliner with a blanket covering Resident 76's body. Resident 76 had bruising on the right side of the face and stitches over left eye. Resident 76 had a tabs monitor connected to the recliner and the shirt Resident 76 was wearing. Observation on 03/01/18 at 8:30 a.m. revealed the resident was sitting in their recliner and observing television. The resident had a bedside table next to the recliner with a mug of water sitting on it. Resident 76 had a tabs monitor connected to the recliner and Resident 76's shirt. The call light was next to the resident and was connected to resident's recliner. Resident 76's face was bruised on the right side and bruising went from under the left side of the chin to the top of the left side of forehead and stitches remained over the left eye. Record Review of Resident 76's progress note 02/21/18 at 9:44 a.m. identified Resident 76 was getting up without staff assistance and tripped over the bedside table while staff were getting Resident 76's walker. Resident 76 had a laceration above the left eye and Resident 76 complained of head pain. Resident 76's primary physician was contacted and recommended the resident be transferred by ground ambulance to SRMC ( Sidney Regional Medical Center). Resident 76 was transported SRMC Emergency Department. Record Review Resident 76's progress note dated 02/21/18 at 9:04 a.m. identified that the Emergency Department Nurse reported that Resident 76 had been admitted to the SRMC with multiple facial fractures and a hemorrhage to the brain. Record Review of Resident 76's fall risk assessment completed on 02/16/18 revealed that Resident 76 was not steady, and was only able to stabilize with staff assistance when walking and turning around when facing the opposite direction while walking. Interview with Resident 76's family on 02/27/18 at 10:30 a.m. revealed Resident 76 had a fall in the resident's room and Resident 76 had facial fractures to the left side of the face, lacerations over left eye and a brain hemorrhage. Interview with NA (Nursing Assistant)-E verified Resident 76 fell in the room and NA-E did not witness the fall as NA-had gone to retrieve a walker for Resident 76. Interview on 03/06/18 at 9:23 a.m. with LPN (Licensed Practical Nurse)-D verified there were no staff in the room at the time of the fall. Interview on 03/06/18 at 10:10 a.m. with the Administrator and Corporate Nursing Consultant verified Resident 76 did have a fall on 02/21/18 after the Fall Risk Evaluation had been completed on 02/16/18 and it had identified the resident was not steady when walking or turning around and required staff assistance to stabilize and staff were not present at the time of the fall. |
2020-03-01 |