| 6995 |
NEBRASKA CITY CARE AND REHABILITATION CENTER, LLC |
285109 |
1420 NORTH 10TH STREET |
NEBRASKA CITY |
NE |
68410 |
2014-12-11 |
323 |
H |
0 |
1 |
9RWM11 |
**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 staff failed to implement interventions and re-evaluate interventions to prevent falls for 3 residents (Resident 28, 41 and 46) and failed to secure medications and chemicals on the secured unit. The facility staff identified a census of 50. Findings are: A. Record review of an Admission record sheet dated 3-10-2014 revealed Resident 41 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 41's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-19-2014 revealed the facility staff assessed the following about the resident; -BIMs (Brief Interview for Mental status) revealed Resident 41 scored a 5. According to the MDS Manuel, a score of 0 to 7 indicated severe impairment. -Required extensive assistance with transfers, bed mobility, dressing, personal hygiene and toilet use. -Falls occasionally. Record review of Resident 41's Quarterly Interdisciplinary Resident Review (QIRR) sheet dated 10-19-2014 revealed Resident 41 scored a 13 on the section that was identified a Devices, Restraints and Falls. According to the information on the QIRR sheet revealed a total score of 10 or above deemed the resident at risk. Record review of a Balance Assessment Screen (BAS) dated 10-19-2014 revealed Resident 41 scored a 3. According to the information on the BAS form, a score of 3 indicated a standing balance test could not be completed without physical help. Record review of Resident 41's Comprehensive Care Plan (CCP) reviewed on 9-10-2014 revealed Resident 41 was identified at risk for injury or falls related to weakness, dementia, poor balance and a history of falls. The goal was Resident 41 would not have any fall related injury requiring hospitalization . Intervention identified on the CCP included Foot wear to prevent slipping, Bed and wheelchair alarm. According to the CCP, this intervention was initiated on 6-09-2013 and reviewed on 9-09-2014. Further review of Resident 41's CCP revealed Resident 41 was incontinent with a goal to prevent Urinary Tract Infections (UTI) and a goal listed here dated 6-13-2013 was to use a chair alarm. Resident 41's CCP had a hand written entry dated 10-20-2014 that identified Resident 41 had a fall with a resulting laceration to the head that required staples. Record review of a Fax sheet dated 10-20-2014 revealed the facility had informed Resident 41's physician that Resident 41 had been sent to the hospital and received 3 staples. Record review of Resident 41's Verification of Investigation (VOI) dated 10-20-2014 revealed Resident 41 was found on the floor with a laceration and contusion noted to the right side of (the) head. According to the VOI dated 10-20-2014, Resident 41 was not able to verbalize what had happened due to impaired cognition related to dementia. Further review of the VOI revealed a section that had an area for staff to specify recommendations/interventions taken to prevent reoccurrence included a low bed, sensor alarms in the w/c (wheelchair) and bed. The VOI did not indicate if the alarm had been attached and sounding with the fall on 10-20-2014. On 12-09-2014 at 11:20 AM an interview was conducted with the Director of Nursing (DON). During the interview, Resident 41's CCP and the VOI dated 10-20-2014 was reviewed with the DON. The DON confirmed that according to Resident 41's CCP, Resident 41 should have had an alarm on prior to the fall on 10-20-2014. According to the DON, the alarm was removed as Resident 41 had not recently fallen. When asked if an evaluation to remove the alarm had been completed, the DON stated no. B. Record review of an Admission Record sheet dated 12-8-2014 revealed Resident 46 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 46's MDS dated [DATE] revealed Resident 46 was identified as independent with Activities of Daily living and required supervision with bathing. Record review of a VOI dated 10-17-2014 revealed Resident 46 had attempted (to) crawl out of the bath tub over the side of the tub instead of opening the tub door and fell . Accord to to the information in the VOI, Resident 46 was sent to the hospital for an evaluation. Further review of the VOI dated 10-17-2014 did not contain information that Resident had been supervised prior to the fall. An interview was conducted with the DON on 12-09-2014 at 2:41 PM. During the interview the DON reported the Bath Aid had set the resident up for the bath and left the room and stepped outside the door. The DON confirmed an evaluation had not been completed for independently bathing for Resident 46. C. Record review of the care plan for Resident 28 revealed: Resident 28 was admitted on [DATE] with the following diagnoses-Dementia, unspecified, with behavioral disturbance; other and unspecified [DIAGNOSES REDACTED]; unspecified essential hypertension; Obstructive chronic bronchitis without exacerbation. Record review of the admission Clinical Health Status record dated 11/06/2014 revealed: Resident 28 scored a 6 on the fall scale. A score of 10 or above deems resident at risk. Record review of the care plan dated 12/01/2014 revealed: At risk for falls related to: Wandering, Use of Medications, New environment, History of falls. Goal-No fall related injuries requiring hospitalization . Interventions-Assess for pain, provide medication or non-pharmacologic pain relief methods and appropriate, assess effectiveness. Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, anti-tippers. Call light or personal items available and in easy reach or provide reacher. Footwear to prevent slipping. Keep environment well lit and free of clutter. Observe for side effects of medications. Orientation to new room and roommate. Therapy services as ordered. Toilet schedule; assist resident to toilet in AM, before/after meals or activities, at HS (bedtime) and PRN (as needed). Provide incontinence cares as needed. A review of the VOI for Resident 28 revealed Resident 28 had fallen on 11/19/2014. Further review of Resident 28's VOI revealed there was no evidence of any new interventions implemented to prevent Resident 28 from further falls. Interview with the ACU (Alzheimer Care Unit) Director on 12/10/2014 at 7:35 AM revealed the following: confirmed that there were no new interventions identified nor were any new interventions care planned. D. During initial tour of the facility Alzheimer's Secured Unit on 12/01/2014 at 12:13 PM revealed the door to the bath house unlocked and the chemicals, Lemon-Eze and Neutral Disinfectant Cleaner, were located in an unlocked cabinet. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Lemon-Eze revealed: -Do not get in eyes, on skin, or on clothing. -Causes serious eye damage. -Keep out of reach. Record review of the Safety Data Sheet dated 02/18/2014 from Ecolab for Disinfectant Cleaner revealed: -Causes digestive tract, eye and skin burns. -Harmful if absorbed through skin or if swallowed. -Causes Respiratory tract irritation. -Corrosive to eyes and skin. -Causes burns to mouth, throat, and stomach. Interview with Alzheimer's Care Unit (ACU) Director on 12/01/2014 at 12:15 PM confirmed that the bath house door on the secured unit was left unlocked as well as the cabinet that contained the chemicals in it was also left unlocked. ACU Director also confirmed these chemical should be locked up and not accessible. E. During observation of meal service in the Alzheimer's Secured Unit on 12/04/2014 from 11:50 AM to 11:55 AM, in a small room connected to the main dining room, Resident 11 was sitting at the dining room table with a medication cup, containing 4 pills, sitting in front of the resident. No staff were in attendance in the small room. Resident 54 was sitting across the table from Resident 11. During this observation Resident 17 entered the room from the main dining room, walked around the table of Resident 11 and Resident 54, and exited the room going back into the main dining area. Observation on 12/04/14 at 11:55 AM revealed Resident 11 picked up the medication cup, dumped the pills in their hand and put the pills in Resident 11's mouth. Resident 11 picked up a glass of juice and took a drink. Observation on 12/04/2014 at 11:57 AM Licensed Practical Nurse (LPN) G walked into the small room adjoining to the dining room and revealed Resident 11 was given pills a few minutes ago and that Resident 11 was independent with medication administration but staff should stay with Resident 11 until Resident 11 took the pills. Interview with LPN G on 12/4/2014 at 11:57 AM, LPN G confirmed that Resident 11 should not be left alone with pills sitting in front of Resident 11 with wandering residents in the area. LPN G also revealed that staff should have stayed with Resident 11 until the pills were swallowed. Interview with the ACU Director on 12/04/2014 at 12:25 PM confirmed that medications were not to be left in front of a resident, unattended, at the dining room table with wandering residents in the area. The ACU director also confirmed that the expectation was to observe the resident swallow the medication |
2018-07-01 |