| 17 |
PERSHING GENERAL HOSPITAL SNF |
295000 |
855 6TH STREET |
LOVELOCK |
NV |
89419 |
2018-02-14 |
655 |
E |
0 |
1 |
OUMW11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review, the facility failed to ensure baseline care plans were created for limited range of motion (ROM), wound care, depression, pain management and fall risk for 3 of 12 sampled residents (Resident #18, #123 and #124). Findings include: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 02/12/18 at 3:46 PM, Resident #18 explained there was an open would located on her right leg and there was no longer an infection present within the wound. It was observed there was a wound vac present on the wound. Resident #18 verbalized she was readmitted to the facility due to the inability to manage the wound vac at home. Resident #18 confirmed base line care plans were not received in writing from the facility which included a care plan regarding the wound care for the resident's thigh. Resident #18's Progress Notes, dated 01/18/18, documented the following regarding wound care: the resident was agreeable to wound care by the facility. A new VAC Ulta was being supplied to the resident. Physical Therapist (PT) removed dry dressing with heavy serosanguinous drainage and mod order. PT cleansed and measured the wound 23 cm X 11 cm X 2.0 cm (centimeters) with undermining from 1 o'clock measuring 6 cm at greatest depth. PT used sharps to remove 30% of the wound dressing, remaining tightly adheredto the resident's right leg. Wound 90% smooth red moist, 10% slough. PT wound was dressed per protocol with VAC, achieving good suction with no troubleshooting. Wound was still progressing. Resident #18's base line care plan lacked documented evidence for wound care for the resident's open wound on the right thigh. On 02/14/18 at 11:26 AM, the Chief Nursing Officer (CNO) confirmed Resident #18 did not receive a copy of the baseline care plan as required. The CNO confirmed a baseline care plan for wound care was not initiated after Resident #18 was readmitted . The CNO verbalized there should have been a baseline care plan to address wound care within 48 hours of readmission. The CNO verified it was her responsibility to complete the baseline care plans for each resident. The CNO explained the Minimum Data Set (MDS) for Resident #18 did not need to be completed upon readmission to the facility because Resident #18 re-entered the facility within 30 days of discharge. The CNO confirmed the facility should have brought forth the resident's care plans when re-entry to the facility occurred. The CNO explained there was not a system in place to initiate baseline care plans or re-evaluate the necessity for the previous admission's comprehensive care plans at readmission. Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/12/18 at 4:14 PM, Resident #123 verbalized he did not recall receiving care plans in writing or a conversation regarding his planned care at the facility. Resident #123's Baseline Care Plan, undated, lacked documented evidence the resident had a [DIAGNOSES REDACTED]. The care plan documented adverse side effects as monitor in the space provided and lacked specific side effects to monitor. The baseline care plan lacked a [DIAGNOSES REDACTED]. On 02/14/18 at 11:15 AM, the CNO confirmed Resident #123's Baseline Care Plan lacked a [DIAGNOSES REDACTED]. The CNO confirmed a copy of Resident #123's Baseline Care Plan was not given to the resident as required. Resident #124 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #124's Morse Fall Scale, dated 02/02/18, documented the resident was at high risk for falls, needs nurse assist for ambulatory aid, the resident was impaired and had difficulty rising from a chair, used chair arms to get up and bounced to rise. The resident keeps her head down when walking, watched the ground, grasped furniture, person or aid when ambulating and could not walk unassisted. On 02/13/18 in the morning, Resident #124 explained she had fallen out of a wheelchair while trying to transfer to a stationary chair in the activities room. The resident explained she was wearing slippery nylon shorts which resulted in the resident slipping from the wheelchair. The resident confirmed there were no injuries and staff assisted the resident off of the floor. The resident explained the staff required her to stay stationary in a chair for about an hour to avoid any additional falls due to the need to monitor her blood sugar levels. Resident #124's nursing progress note, dated 02/13/18, documented Resident #124 attempted to transfer from wheelchair to a recliner chair at 6:40 PM on 02/12/18. The resident was wearing nylon shorts that resulted in the resident slipping to the floor. No damage reported to the resident's amputated site, no bruising or redness noted. Blood sugar-255 and blood pressure, 126/76. Resident #124's care plans, lacked documentation the resident was absent of right leg below the knee, a fall risk, and required transfer assistance. On 02/14/18 at 11:22 AM, the Chief Nursing Officer (CNO) explained a fall care plan for Resident #124 was initiated on 02/13/18, as a result of the resident's fall. The CNO confirmed the facility was unable to locate the fall care plan for the resident and verified it was not in the resident's clinical record. The CNO confirmed a baseline care plan for high risk for falls was not initiated for Resident #124. The CNO verbalized a baseline care plan should have been initiated by the facility as a result of the Morse Fall Scale having provided evidence the resident was a high risk for falls. The CNO verbalized Resident #124's base line care plan for high risk for falls should have been completed within 48 hours of the resident's admission to facility. The facility policy titled, Falls and Fall Prevention, undated, documented the facility was to evaluate and identify residents at risk for falling. The facility was to implement protocols and interventions directed toward reducing falls and injuries to residents within the facility. The facility will continuously re-evaluate residents when falls occur. |
2020-09-01 |