| 54 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2019-10-16 |
657 |
D |
0 |
1 |
LI3Z11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to review and update a resident's care to reflect resident's pain management for 1 of 12 sampled residents (Resident #8) and include measures taken to prevent further occurrences of falls after a resident's fall for 1 of 12 sampled residents (Resident #15). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/14/19 at 9:53 AM, Resident #8 was in bed in resident's room and verbalized having a headache and pain in the left groin area. Resident #8's physicians orders for pain medication documented: - 09/10/19, [MEDICATION NAME] 50 microgram (mcg)/hour (hr.) 1 patch trans dermally at bedtime every 3 days related to other chronic pain - 09/10/19, [MEDICATION NAME] tablet 50 milligrams (mg), 1 tablet by mouth every 6 hours as needed for headache - 03/21/16, [MEDICATION NAME] capsule 75 mg, 75 mg by mouth three times a day for other chronic pain - [MEDICATION NAME] HCl tablet 10 mg, 10 mg by mouth every 8 hours as needed for pain related to other chronic pain, - Tylenol tablet 325 mg, 2 tablets by mouth every 4 hours as needed for mild pain - [MEDICATION NAME] tablet, 5 mg by mouth every 8 hours as needed for moderate pain related to other muscle spasm - [MEDICATION NAME]-ASA-Caffeine capsule 50-325-40 mg ([MEDICATION NAME]-Aspirin- Caffeine) 1 capsule by mouth every 8 hours as needed for headache Resident 8's Medication Administration Record [REDACTED]. Resident #8's Care Plan for pain medication to include [MEDICATION NAME] and [MEDICATION NAME], was last revised on 07/30/18. Resident #8's Care Plan for acute/chronic pain related to arthritis and depression was revised on 04/06/18. Resident #8's Care Plan for pain lacked documented evidence of a revision or update. On 10/15/19 at 10:30 AM, the Director of Nursing (DON) confirmed the Care Plan had not been updated to reflect Resident #8's pain. The DON verbalized the resident's Care Plan should have been updated every quarter. Resident #15 Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician visit progress note dated 10/11/19, revealed Resident #15 was seen by the attending physician on 10/11/19, had fall as recorded problem and increased risk of falling documented. A Quality Review Report dated 10/11/19 documented at 2:30 PM Resident #15 was found on the floor, sitting. Resident was assisted back to bed and examined. Resident #15 was trying to transfer into wheelchair when slipped and fell on the floor. An Incident/Accident internal investigation report dated 10/11/19 documented at 2:30 PM Resident #15 was found on the floor. The form indicated measures taken to prevent further occurrence of similar incident/ accident had to be added to the Resident's Care Plan. A Care Plan initiated on 09/26/18, indicated Resident #15 was at high risk for falls related to [MEDICAL CONDITION], cognitive loss and dementia and possible side effects of [MEDICAL CONDITION] drugs. The Care Plan indicated as intervention to follow the facility fall protocol, to have the bed at lowest and the door open for better monitoring. The goal was to reduce the risk for falls. A Care Plan initiated on 11/16/18, indicated Resident #15 had an actual fall without injury related to weakness with transfer abilities. The Care Plan had been revised on 05/25/19, with a goal specifying the resident would resume usual activities without further incident to the review date and indicated 08/25/19 as a target date. The Care Plan documented as interventions: Resident #15 to be assessed and to have documented any new complaints of pain, new bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture and agitation. Other interventions included to check the range of motion as tolerated by resident, to continue interventions on the at-risk plan, for no apparent acute injury to determine and address causative factors of the fall, to promote resident with activities promoting exercise and strength building where possible and to suggest resident to call for nursing assistance. Resident #15's Care Plan lacked documented evidence of being revised on the specified target date and after the Resident #15's fall on 10/11/19 and no change in interventions were noted after the resident's fall. On 10/15/19 at 10:49 AM, the DON verbalized a resident's Care Plan should have been updated after a resident's fall with or without injury. The DON confirmed the Care Plan had not been updated to reflect Resident #15's fall and no change in interventions were documented after Resident #15's fall incident on 10/11/19. The Facility Policy titled Fall prevention, last revised on 11/2017, documented the resident's plan of care shall be updated with the plan that is being used to prevent falls. The Facility policy titled Care Plans, last revised on 03/22/17, documented each resident will have a comprehensive person-centered care plan developed by the interdisciplinary team. These care plans will be updated as the needs of the resident change and reviewed at least every 92 days by the interdisciplinary team. The care plan must include the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. |
2020-09-01 |