| 5462 |
GOOD SAMARITAN SOCIETY - WOOD RIVER |
285198 |
1401 EAST STREET |
WOOD RIVER |
NE |
68883 |
2017-03-22 |
323 |
K |
1 |
1 |
HUVK11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review, and interview; the facility failed to ensure 2 residents (Residents 30 and 42) of 2 sampled were supervised during a whirlpool bath and failed to protect 1 resident (Resident 84) from an accident while being transported in the facility van which had the potential to affect 42 residents. The facility also failed to ensure chemicals were secured to protect residents on the SCU (Special Care Unit) from potential ingestion, skin irritation or eye irritation which had the potential to affect 11 of the 18 residents on the SCU. The facility census was 59. Findings are: [NAME] Observation on 3/22/2017 at 11:58 AM revealed Resident 42 was in the bathhouse in the whirlpool tub filled with water unattended. Interview on 3/22/2017 at 11:58 AM with ED (Executive Director) revealed the resident was in the whirlpool tub alone without supervision. Interview on 3/22/2017 at 12:37 PM with NA (Nursing Assistant) K revealed Resident 42 was left alone in the whirlpool bath as NA K went out for break. NA K went on to say the other NA's had instructed NA K it was ok for Resident 42 to be left unattended while in the whirlpool tub. Interview on 3/22/2017 at 12:10 PM with Nurse BB revealed Nurse BB was not sure if the resident had been assessed to be in the whirlpool alone. Nurse BB revealed Resident 42 did not get left in the bathroom alone due to being a fall risk. Interview with Nurse CC revealed NA K did not notify Nurse CC of Resident 42 being left in the bath house alone before taking a break. Nurse CC further stated Resident 42 was not safe to be left alone in the whirlpool. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/6/17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 8 out of 15 which indicated Resident 42 had moderate cognition problems. Resident 42 required limited to extensive assist with mobility tasks and bathing. Review of Resident 42's Care Area Assessments (CAA's - A more in-depth assessment to aid in the development of a resident-specific care plan based on identified problems, needs, and strengths) for Activities of Daily Living (ADLs) dated 1/12/17 revealed, Resident needs assistance with all ADLs recently had a fall that resulted in a fracture. Review of Resident 42's CAAs for Falls dated 1/12/17 revealed, Resident had a recent fall that resulted in a fracture to right second metatarsal (toe ) is at an increased risk for further falls r/t (related to) factors that include but are not limited to weakness and needs assistance with all ADLs Review of Resident 42's Care Plan dated 12/23/15 revealed Resident 42 had impaired cognitive function related to Alzheimer's disease and hallucinations/delusions. Further review of Resident 42's Care Plan revised 1/6/17 revealed Resident 42 required assistance of 1 staff with bathing. Resident 42's Care Plan did not state that Resident 42 was safe to be in the whirlpool unattended. Resident 42's Care Plan revised 6/12/14 further stated Resident 42 was at risk for falls related to impulsivity and needed reminders to wait for assistance from staff. Interview with NA M on 3/22/17 at 1:28 PM revealed NA M had left Resident 42 in the whirlpool alone because NA M was told by administrative staff that it was care planned for Resident 42 to be able to sit in the whirlpool alone. Further interview with NA M revealed it was common practice to leave Resident 30 unattended in the whirlpool and that staff usually left and took their 30 minute break or went to do their charting for the day. Interview with Medication Aide (MA) X on 3/22/17 at 1:43 PM revealed MA X had left Resident 30 unattended in the whirlpool when providing baths. Review of Resident 30's MDS dated [DATE] revealed Resident 30 had a BIMS of 9 out of 15 indicating moderate cognitive impairment and had a [DIAGNOSES REDACTED]. Review of Resident 30's Care Plan dated 10/26/15 revealed Resident 30 preferred a whirlpool and requested time to soak, but bath aide must remain in bath house with resident. Review of Resident 30's Progress Notes dated 3/18/17 revealed Resident 30 was found on the floor after feeling light headed while getting ready for bed. Further review of Resident 30's Progress Notes revealed episodes of confusion documented on 3/18/17 and 2/15/17. Review of the facility's procedure for bathing revised 3/17 revealed, 5. Do not leave resident unattended. Resident may be unattended during bath per his/her request and if assessed by the interdisciplinary team to be safe/independent. Interview with the ED on 3/22/17 at 2:30 PM confirmed that neither Resident 42 nor 30 had been assessed to be safe to be left unattended in the whirlpool tub. The Immediate Jeopardy was abated to an [NAME] level on 3/22/17 at 3:30 PM when the ED stated all staff who had the potential to assist residents with bathing had been educated to not leave any residents alone while in the whirlpool tub. B) Review of the undated census sheet for Resident 84 revealed an admission date of [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident 84 had no cognition problems. Resident 84 was independent with setup help only with bed mobility. The resident did not walk and required extensive assistance of one staff person for transfers, dressing, toileting, and personal hygiene. Review of the Progress Notes dated 5-6-16 revealed Resident 84 was picked up by the facility van from the Dialysis Unit to be transported back to the facility. The employee who drove the van failed to secure the front wheels of the wheelchair prior to leaving and, when the van crossed over an intersection, the resident's wheelchair tipped over backwards with the resident in it. The resident hit the back of the resident's head on the back wall of the bus. The resident was assessed for injury by the staff person then called 911 to assist with lifting the resident and to transfer to the hospital for an evaluation. A CXR (chest x-ray) and CT scan of the head were completed, both were negative. The resident returned to the facility. Review of the physician progress notes [REDACTED]. Review of the facility investigation report revealed the interventions initiated were: 1) Signs were made and posted into each of the facility vehicles (van and bus) with instructions to follow prior to the staff being able to drive the vehicle. The instructions revealed: -strap down and tighten all four latches to the wheelchair -put the seatbelt around the resident -attempt to move the wheelchair and ensure that it is secure 2) The van driver involved was educated. Observation on 3-21-17 at 10:22 AM of Staff J revealed a resident in a wheelchair was loaded into the van and a 4 point wheelchair harness and seatbelt was applied. The driver made sure the wheelchair was secure. Observation inside the van revealed the absence of a sign posted with instructions on wheelchair/seatbelt application. Observation on 3-21-17 at 12:10 PM accompanied by Staff J of the facility bus revealed the absence of a sign posted with instructions to the driver on the wheelchair/seatbelt application. Interview on 3-21-17 at 12:10 PM with Staff J confirmed there were no signs in either vehicle and Staff J revealed there never had been. Interview on 3-21-17 at 12:35 PM with the SW (Social Worker) revealed the signs were made at the time of the incident by the SW. The SW thought either the ADM (Administrator) or the DON (Director of Nursing) had posted them in the vehicles. Interview on 3-21-17 at 2:20 PM with the DON confirmed the DON did not post the signs and confirmed no education was provided to any of the other staff who drove the van or bus after the incident. Review of the policy Before Operating a Vehicle with Wheelchair Lifts, Wheelchair Securement Systems and/or Seat Belt Systems dated 5/2013 revealed a Vehicle Knowledge Checklist form (GSS: Good Samaritan Society #655) should be completed prior to a driver transporting resident in a wheelchair. A Transporting Residents in Wheelchair Checklist (GSS #359) shall be satisfactorily completed prior to a staff person driving and annually thereafter. Interview on 3-21-17 at 2:22 PM with the Administrator confirmed there were 4 staff trained to drive the van/bus to transport residents and per the policy the competencies should be completed annually. The ADM confirmed last van competencies completed on the staff were in (YEAR) and not done in (YEAR) or yet in (YEAR). Review of personnel files revealed : 1) Staff J last competency on driving the facility van/bus was completed 12-28-15. 2) SW last competency on driving the facility van/bus was completed 12-29-15. 3) DON last competency on driving the facility van/bus was completed 5-26-15. 4) Staff K last competency on driving the facility van/bus was completed 1-20-17. C) Observation on 3-8-17 at 08:50 AM on the SCU (Special Care Unit) revealed the Dirty Utility room door, located by the Bath House, was shut but not secured/locked. When the door was gently pushed, it opened. Observation inside the room revealed a spray bottle of Virex, a disinfectant cleaner, on top of the counter. Observation on 3-8-17 at 8:50 AM on the SCU in the Bath House revealed the door to the room was wide open and no staff was in view of the door. In the Bath House was a cabinet with the doors wide open and a spray bottle of Virex sat on the shelf. Interview on 3-8-17 at 8:50 AM with Staff X revealed Staff X had been giving baths this morning before breakfast, then stopped to assist at the breakfast time and was back to start to give baths again. Observation were conducted on 3-8-17 at 8:52 AM of a cupboard in the SCU in the DR (dining room) above the hand wash sink. The cupboard had locks on both cabinet doors but the doors were unlocked. The cupboard contained a full bottle of Wax Glue-Max. The DR contained 14 residents sitting around at various chairs and wheelchairs. One resident, Resident 82, was wandering in the halls. At 8:55 AM, Resident 82 entered into the Bath House, as the door was wide open and was beside the cabinet which held the Virex. Staff P came out of the room directly across from the Bath House and redirected the Resident 82 out of the Bath House and shut the door. Observation on 3-8-17 at 11:45 AM on the SCU revealed the Utility Room located by the Bath House. The door was shut but not secured/locked. Inside on the counter was the bottle of Virex disinfectant. In a cupboard on the bottom shelf, there was several Isolyser LTS spill kit packets. On the packets was 'Precaution: Not for Internal Use.' Observation of the bathhouse next door revealed the door was shut but the door was not secured and, with a gentle push on the door, the door opened. Inside the room, the cabinet that had previously been opened was secured shut with a padlock. Observed on top of the cabinet was a clear basket full of fingernail polish and a full bottle of fingernail polish remover. Observation on 3-8-17 at 11:50 AM revealed the Staff GG exit the Dirty Utility room and shut the door but did not pull it shut to ensure the door was secured. At 11:51 AM, a gentle push on the door opened the door. No residents were in the hallway wandering at this time. Observation on 3-8-17 at 12:25 PM revealed the cupboard in the SCU DR above the hand wash sink had unlocked cabinet doors. The cabinet had been cleaned and the Wax Glue-Max was gone. Observation on 3-8-17 at 12:39 PM revealed the door to Bath House was open about 12 inches and no staff was in sight of the room. Observation on 3-8-17 at 1:50 PM revealed the door to the Bath House was open about 1/2 inch. Inside the room was the basket at head height of fingernail polish and full bottle of fingernail remover. The whirlpool on the bottom right side had a door with a lock on it. The door opened and inside was the whirlpool disinfectant concentrate hooked up to the hose to the tub. The door was not locked. Observation on 3-9-17 at 10:30 AM revealed the Dirty Utility room door was shut but not latched secure. With a gentle push on the door, the door opened and observation revealed a bottle of Virex disinfectant spray on the counter. Observation on 3-9-17 at 10:38 AM revealed Resident 6 in the Dining Room in the SCU, which was located 1 room away from the Bath House and Dirty Utility room. Resident 6 was exit seeking with attempts to push open the exit door to the courtyard door several times At 3-9-17 at 1:45 PM, Resident 6 was across the hall from the Bath House rummaging through some dresser drawers in the resident room. Review of the MSDA (Material Safety Data) sheets of the chemicals observed revealed they were classified as harmful for oral consumption, skin corrosion/irritation, and serious eye damage/eye irritation. Interview on 3-9-17 at 4:00 PM with the ED (Executive Director) revealed the expectation was to have the doors shut and secured at all times when a staff was not in the room when chemicals are in the room. Interview with the SW (Social Worker) on 3-22-17 at 3:30 PM revealed 11 residents who live on the SCU rummaged and were independent with locomotion. |
2020-01-01 |