| 6303 |
HILLCREST HEALTH & REHAB |
285133 |
1702 HILLCREST DRIVE |
BELLEVUE |
NE |
68005 |
2016-04-27 |
323 |
G |
1 |
0 |
IO6811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 2 residents (Resident 6 and Resident 9), and failed to identify and implement additional interventions for 1 resident (Resident 9). The facility staff identified a census of 109. Findings are: A. Record review of an Admission Assessment sheet printed on 4-25-2016 revealed Resident 6 was admitted to the facility on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 3-29-2016 revealed the facility staff assessed the following about Resident 6: -Short and long term memory problems. -Required supervision for personal hygiene,dressing, eating and locomotion off the unit. -Required extensive assistance with bed mobility, transfers, locomotion on the unit and toilet use. -Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. -[DIAGNOSES REDACTED]. -1 fall since admission to the facility. Record review of a Fall Risk Assessment sheet dated 3-17-2016 revealed Resident 6 scored a 12. According to the Fall Risk Assessment sheet dated 3-17-2016, a score of 10 or above identified that a resident should be considered high risk for potential falls. Record review of Resident 6's Care Plan (CP) printed on 4-25-2016 revealed an effective date of 3-17-2016 to present. Further review of Resident 6's CP identified Resident 6 had falls. The goal was that Resident 6 would not have any falls with injury. The intervention listed on the CP included Falling Leaf as indicated, encourage to use call light, Physical and Occupational therapy as ordered. Further review of Resident 6's CP revealed an additional problem area that Resident 6 was at risk for falls and Resident 6 will have reduced risk for falling. The goal was Resident 6 would demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days. Interventions listed on the CP included keeping the area free of obstructions, place call bell/light within easy reach, respond promptly to calls for assistance to the toilet, use alarm to monitor attempts to rise and foot wear to fit properly and have non-skid soles. Record review of a Nursing Tech Care Plan ( NTCP, sheet of paper that identified basic information and care needs of Resident 6) dated 3-17-2016 revealed Resident 6 was to have alarms that were pressure (activated) to the bed and Tab alarm. Record review of the NTCP dated 3-18-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of the NTCP dated 3-23-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of a Clinical Notes Report (CNR) sheet dated 3-25-2016 revealed Resident 6 was found sitting on the floor. The alarm was sounding but very softly. According to the CNR dated 3-25-2016 the tab alarm had been placed on Resident 6 when in bed or a chair. Record review of a Causal Factors sheet signed by Registered Nurse (RN) C on 3-25-2016 revealed interventions were to place Resident 6 onto a falling star program, placed a chair alarm, relocated alarm box out of resident sight and blue pads at bed side. An interview on 4-26-2016 at 10:23 AM was conducted with RN C. During the interview review of the NTCP dated 3-18-16 and 3-23-16 for Resident 6 was completed. During the interview, RN C confirmed the interventions for the pressure alarm and Tabs alarm was not identified on the NTCP. RN C stated they should have been. When asked if the pressure alarm had been in place when Resident 6 was found on the floor, RN C reported the pressure alarm was not in place. When asked what interventions were implemented after Resident 6 was found on the floor, RN C reported the pressure alarm and blue pad. Record review of a CNR sheet dated 3-26-2016 revealed Resident 6 was on the floor and the alarm had not sounded. Record review of a CNR dated 3-27-2016 revealed Resident 6's practitioner was informed that Resident 6 was having pain and the right leg was externally rotated. The practitioner ordered an x-ray of the right hip. Record review of a Radiology Report dated 3-27-2016 revealed the results of the x-ray was that Resident 6 had a right femur fracture. On 4-26-16 at 10:51 AM an interview was conducted with RN D. During the interview, review of the facility investigation was completed with RN D. When asked if the pressure alarm and blue pad was in place, RN D stated I'm not sure. Record review of information sheet titled Accidents dated 3-28-2016 revealed the date of the incident was 3-26-2016. The Accident sheet identified bed and chair alarms were to be used and the interventions to prevent the accident/incident from reoccurring was identified as a bed and tab alarm were on the resident and functioning with frequent checks by team member. Further review of the Accident sheet dated 3-28-2016 revealed there was not any indication the mat at bed side was in place or why the pressure alarm did not sound. On 4-27-2016 at 2:21 PM a phone interview was conducted with Licensed Practical Nurse (LPN) F. During the interview, review of Resident 6 being found on the floor on 3-26-2016 was conducted with LPN F. LPN F confirmed during the interview that (gender) was the nurse for Resident 6 on 3-26-2016. When asked if the sensor alarm and blue pad was next to Resident 6's bed, LPN F stated no, they weren't. LPN F further reported that the reason (gender) remembered was the Nurse Tech was going to place one under the resident. B. Record review of Resident 9's Face Sheet dated 04/26/2016 revealed that Resident 9 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident 9's Minimum (MDS) data set [DATE] revealed that Resident 9 had a Brief Interview for Mental Status (BIMS) Score of 4; (BIMS scores between 0 and 7 indicate severe cognitive impairment). Record review of Resident 9's care plan for falls dated 04/26/2016 revealed a goal of will have no fall with injury and the following interventions to prevent falls: - Alarms in place all the time/TAB, - Frequent rounding, - Engage patient in activities with rec therapy, - Offer snacks and redirection in the afternoon, - Fall risk assessment completed, - Encourage to use call light. Record review of a Fall Risk assessment dated [DATE] revealed it was started but not completed. This was confirmed by Registered Nurse (RN H) on 04/26/2016. A second fall risk assessment was completed on 04/18/2016 and revealed that Resident 9 had a fall risk score of 16. The assessment states high risk is a score of 10 or above. Record review of Nursing Progress notes, dated 04/10/2016, revealed Resident 9's bed alarm was sounding and Resident was found sitting on the floor. No injuries noted Record review of Nursing Progress notes, dated 04/23/2016, revealed Resident 9 was found on the floor in front of Resident 9's wheel chair. Tab alarm was attached but did not disconnect from the alarm box and sound. No injury noted. Interview with RN H, on 04/26/2016 at 11:18 AM revealed there were no new interventions identified and put in place following two of Resident 9's falls-04/10/2016 fall and the 04/23/2016 afternoon fall. |
2019-04-01 |