| 9101 |
HUNTINGTON PARK CARE CENTER |
285251 |
1507 GOLD COAST ROAD |
PAPILLION |
NE |
68046 |
2014-10-16 |
309 |
J |
1 |
0 |
BXXD11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D Based on interviews and record review, the facility failed to implement interventions to protect residents from potential harm after statements of suicidal ideation for two residents (Residents 6 and 10). The facility had a total census of 91 residents. Findings are: A. Resident 6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 6's 9/16/14 MDS (Minimum Data Set; a comprehensive assessment used for care planning) under Staff Assessment of Resident Mood revealed Resident 6 was identified as having stated life isn't worth living, had wishes for death, or attempts to harm self for 2-6 days out of the last 2 weeks. A review of Resident 6's Care Plan revealed a focus area dated 8/1/14 regarding Resident 6's [DIAGNOSES REDACTED]. Interventions for this focus area included the following: monitor/document report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky behavior, intentional harm or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, or impaired judgment or safety awareness. A review of Progress Notes for Resident 6 revealed a note dated 9/27/14 at 5 PM that stated Resident 6 had a plan to kill self. Resident 6 would not state what Resident 6's plan was. The Progress Note stated Resident 6 told staff members to get out of the room and slammed the door behind them. According to the note, RN A (Registered Nurse) went to check on Resident 6 20 minutes later and could not open door as Resident 6 had backed wheelchair up against room door. RN A entered room through the bathroom connected to another room. Resident 6 refused to respond to RN A and spit in RN A's face. A Progress Note dated 9/27/14 at 6:50 PM stated Resident 6 was transferred to the hospital for suicidal thoughts with a plan and delusions. In an interview on 9/30/14 at 2:32 PM, RN A reported after Resident 6 told staff members to leave the room, Resident 6 was in room alone for 15 minutes while RN A contacted House Supervisor. RN A reported after checking on Resident 6 and discovering Resident 6 had placed a wheelchair in front of the room door so it could not be opened, Resident 6 was alone in room while arrangements were made to transfer Resident 6 to the hospital. RN A stated RN A did not check Resident 6's room for potentially dangerous objects. In an interview on 9/30/14 at 3:27 PM, the Director of Nursing reported Resident 6 should not have been left alone in the room when Resident 6 was making statements about harming self. The Director of Nursing reported Resident 6 should have been brought to the desk or a staff member should have stood in Resident 6's doorway. B. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's 8/5/14 MDS revealed Resident 10 had no thoughts of being better off dead or hurting self in some way with in the previous 2 weeks. Resident 10 had a total score of 7 on the Resident Mood Interview, PHQ-9 (an assessment of resident mood based on resident response to interview questions). A review of Resident 10's care plan revealed a focus area dated 6/17/14 related to depression due to admission with use of medication of [MEDICATION NAME] (a medication for depression) and [MEDICATION NAME] (a medication for anxiety). Resident 10's goal for this focus areas was for PHQ9 score to not exceed 6. Interventions for this focus area included the following: monitor/document report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky behavior, intentional harm or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, or impaired judgment or safety awareness. In interviews on 9/30/14 at 2:45 PM and 3:06 PM, LPN B (Licensed Practical Nurse) reported a family member of Resident 10 had found an empty insulin syringe in Resident 10's drawer and brought it to LPN B. LPN B reported the family member stated Resident 10 had kept it in case Resident 10 wanted to kill self. LPN B reported LPN B disposed of the syringe and reported the incident to the next shift. A review of Resident 10's Progress Notes revealed a note dated 9/27/14 at 5 PM. The Progress Note stated Resident 10's family member had found a syringe in Resident 10's top drawer. Resident 10 had told the family member the syring was in a drawer in case Resident 10 wanted to kill self. According to the Progress Note, the syringe was disposed of in a needle box. A Progress Note dated 9/28/14 referred to an incident in which the syringe was found in Resident 10's drawer but did not include any documentation of follow up being completed regarding the incident. In interviews on 9/30/14 at 3:20 PM and 4:17 PM, the Director of Nursing reported having heard either that morning or the evening before that a family member of Resident 10 reported there may have been a syringe in Resident 10's room. The Director of Nursing was not aware that Resident 10 had made statements of self-harm or that the nursing staff had seen the syringe. According to the Director of Nursing, no follow up had been completed regarding the incident. The Director of Nursing reported the information about the residents making the statement regarding self-harm should be kept at the desk during the day and check on the resident every 10-15 minutes at night. The resident's room should be checked for any item that the resident could harm self with. C. A review of the facility policy/procedure titled Suicide Precautions dated 10/02 stated the following: - Physician order for [REDACTED]. (Medical Doctor) and family contacts will be reflected in interdisciplinary notes. - Social Services will be contacted. - Documentation regarding behaviors and verbal clues that the resident is despondent will be reflected in the charting every shift. - The resident will be monitored every thirty minutes. - Medication administration will be monitored to make sure that all medications dispensed are swallowed. - All sharp objects will be removed from resident's room. This includes, but not limited to, safety razors, glassware, belts, shoelaces, all electrical cords, light bulbs and any self-administered medications. - Plastic silverware will be used for all meals. - All wastebasket plastic liners will be removed from the room. D. The following interventions were implemented by the facility on 9/30/14 and 10/1/14 to abate the immediacy of the situation and protect residents with potential suicidal ideation. 1. All current residents of the facility were screened for depression and suicide ideation on 9/30/14 or 10/1/14. Resident 6 was still in the hospital on [DATE]. An appointment was arranged for Resident 10 with the facility's consulting psychiatrist on 10/1/14. 2. The facility Suicide Precautions Policy was updated to state the following: - Suicide precautions will be implemented immediately once the need is determined. - A physician's written order shall be obtained within four hours of implementation of suicide precautions. - The need for suicide precautions will be reassessed daily for continued need by a physician. - If a Resident is found to have SI (Suicide Ideation) and has a plan, a designated staff member will stay with the resident for the resident should not be left alone. - Staff is to stay with resident and ensure safety by modification of the resident's environment. Remove any sharp objects such as razors, glassware, belts, shoelaces, light bulbs. Etc. -If suicide precautions are in place staff should monitor resident every 15 minutes or more frequently as needed, with no time lapse of greater than 15 minutes. 3. Education was provided to staff on the new suicide Precautions Policy starting with the evening shift on 9/30/14. Nursing staff members were educated on suicide precautions prior to start of night shift on 9/30/14 and day shift on 10/1/14. Education was provided to staff not working evening shift or night shift on 9/30/14 or day shift on 10/1/14 was provided on 10/1/14 in person or via telephones. This included activity and social services staff members. Nursing staff members on leave or who could not be reached were informed they would not be allowed to work until education was completed. |
2016-11-01 |