cms_OR: 5
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 657 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to revise care plans in the areas of nutrition, food preferences and mood for 3 of 21 sampled residents (#s 8, 28 and 38) whose care plans were reviewed. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. The 11/2018 signed physician's orders [REDACTED]. On 12/8/18, the resident was readmitted to the facility. The 12/2018 signed physician's orders [REDACTED]. The previous diet orders were discontinued. The current nutritional care plan, last revised on 12/13/18, and the current Kardex Report (CNA Care Plan) continued to reflect the CCHO diet order as well as the orders for the tube feeding. In a 2/26/19 interview at 1:59 PM, Staff 10 (Resident Care Manager-LPN) confirmed both orders were reflected on the care plan. 2. Resident 38 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. On 2/1/19, the resident moved to a new room on a different floor of the facility. A 2/10/19 progress note identified the resident became upset because staff did not allow a slide board transfer into a shower chair. The nurse counseled the resident and stated the sliding board transfer was unsafe. The resident refused the offered Hoyer lift transfer and shower. On 2/11/19, a follow-up care conference was held with the resident. The 2/10/19 shower refusal was discussed with a plan to update the care plan to state the resident could use a drop arm bedside commode as a shower chair as the resident had already been using this in her/his previous unit within the facility. On 2/11/19, the ADL Self Care Care Plan was updated to reflect the resident's preference to use the commode chair with drop arm for showering, using a sliding board transfer, approximately 10 days after the resident was moved to a different room and floor in the facility. In a 2/26/19 interview at 1:36 PM, Staff 10 (Resident Care Manager-LPN) stated when residents transferred from one part of the building to another, the care plan and medications were an important part in knowing the resident's needs and preferences for care. Staff 10 confirmed the care plan did not reflect the resident's individualized showering method until 2/11/19. 3. Resident 28 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Resident 28's revised 4/5/18 Care Plan that addressed mood, included a history of suicide behavior, threats, outbursts when frustrated, negative verbalizations and frequent complaints. Interventions included initiating 15 minute checks as needed, interviewing the resident per suicide policy protocol to assess suicide intent, medications per physician orders, mental health evaluation as needed, and to notify DNS and/or Administrator at time of the incident after resident is safe. Progress notes on 2/27/18, 3/15/18, 6/11/18, 2/19/19, 2/20/19, 2/21/19 and 2/23/19 documented Resident 28's verbalizations of suicide. Resident 28's Care Plan was not revised to reflect individualized interventions or approaches to address suicidal verbalizations. No revisions were made to the care plan since 4/5/18. In an interview on 2/25/19 at 10:11 AM, Staff 10 (Resident Care Manager-LPN), stated she thought approaches were on the resident's Care Plan. Upon review, she acknowledged no approaches were documented. | 2020-09-01 |