cms_OR: 84
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 84 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 657 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to revise and update care plans for 3 of 9 sampled residents (#s 5, 6 and 15) reviewed for accidents, pressure ulcers, respect and dignity. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. A complaint was received on [DATE] indicating Resident 5 had a fall on [DATE] in the facility that resulted in a [MEDICAL CONDITION]. An undated Kardex (a form utilized by CNAs to guide care provided to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. Witness 5 (Complainant) reported the resident had a fall. Interviews completed on [DATE] indicated Staff 43 (CNA) and Staff 40 (CNA) were both transferring the resident to the bed side commode when the battery on the sit-to-stand machine died . Staff 40 had to go down and exchange the batteries. Upon Staff 40s return the resident stated My legs are giving out and instead of using the sit-to-stand machine to lower the resident Staff 43 and Staff 40 both manually lowered the resident to her/his knees and then laid the resident down with pillows under her/his head. -Staff 44 (LPN) came down the hall and saw Staff 40 getting new batteries for the sit to stand machine. When Staff 44 entered the room the resident was on the floor with a Hoyer (mechanical lift) sling (a device used to suspend the resident in the Hoyer) by the resident's bed. They had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave the resident a pain pill after they used the Hoyer to get the resident back into bed. Resident 5 began calling out 20 to 30 minutes after being in bed and Staff 44 was advised to send the resident to the hospital. -Hospital x-rays revealed a mildly displaced right intertropchanteric (hip) fracture, a non-displaced (the broken bones remain aligned) right proximal (just below the knee) fibular (the smaller shin bone) fracture and further indicated an irregularity in the posterior aspect of the medial tibial (large shin bone) plateau may represent a nonspecific fracture. Record review revealed the resident readmitted to the facility on [DATE]. The Comprehensive Care Plan revealed the following: -A Comprehensive Care Plan initiated on [DATE] (six days after the resident readmitted on [DATE]) indicated Resident 5 had a [MEDICAL CONDITION] related to a fall and [MEDICAL CONDITION] ([MEDICAL CONDITION] joints). Staff were directed to monitor and document pain. On [DATE] (nine days after the resident readmitted on [DATE]) a revision staff were directed to bridge and off load the right hip due to the fracture. -A Comprehensive Care Plan revised on [DATE] (17 days after the resident readmitted ) indicated Resident 5 had a self care deficit related to decreased mobility, reconditioning and obesity. The resident was a two person assist and staff were directed to utilize a Hoyer during transfers and toileting. The resident was a three person assist with bed mobility. -A Comprehensive Care Plan revised on [DATE] (17 days after the resident readmitted ) indicated Resident 5 was a moderate risk for falls related to cognitive problems, gait and balance issues, incontinence and medication drug use. The resident was a two person assist and staff were directed to utilize a Hoyer during all transfers. -A review of the Comprehensive Care Plan revealed no documentation regarding Resident 5's POLST (Provider Orders for Life-Sustaining Treatment) or Advance Directive (A written statement of a person's wishes regarding medical treatment) status. On [DATE] at 11:55 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the care plan was not updated timely. Staff 2 stated care plans should be updated within 48 hours. She further stated the POLST and advance directive should have been on the resident's care plan. 2. Resident 6 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident 6 was cognitively intact. The Comprehensive Care Plan indicated the resident had behavioral, cognitive, psychiatric diagnosis ([MEDICAL CONDITION], anxiety and dementia) and was experiencing [MEDICAL CONDITION] of [MEDICAL CONDITION] disorder when she would yell, cry, verbalize belief in conspiracies and would get agitated easily with staff and other residents. Staff were directed to monitor behaviors every shift, ask permission prior to moving or handling any of the resident's items and ensure all of resident's belongings were labeled. Interventions in place included redirection, change of position, return to room, one to one interaction, toileting, assess for pain and offer soft drink. A revision on [DATE] indicated the resident had change in behavior and was yelling at staff, making statements of staff not caring and no one would care for her/him. Staff were directed to notify the nurse of behaviors and redirect the resident. On [DATE] at 1:47 PM Staff 52 (CNA) stated the resident was able to state her/his needs, was highly sensitive and was often very accusatory of staff. The resident often indicated that staff did not provide care for her/him when they had just completed ADLs or a specific request. Staff 52 stated she would prefer two staff in the room when providing care due to the accusations. On [DATE] at 8:45 AM, 9:07 AM and 1:25 PM Staff 17 (CNA), Staff 42 (CNA) and Staff 37 (CNA) all stated the resident was able to state her/his needs. The resident was known to make false accusations regarding staff not providing care, when in fact the staff provided the care or request. The resident was known to be hyper-focused and hyper-sensitive. They preferred to have another staff person in the room when providing ADL care, due to the resident's accusations. On [DATE] at 1:15 PM Staff 11 (RNCM) and Staff 51 (LPN/RCM) acknowledged and agreed the resident care plan should be updated to reflect the resident was known to make accusations and staff would prefer too staff persons in the room while providing ADL care. 3. Resident 15 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] care plan revealed Resident 15 had mixed incontinence and she he used a bedpan if requested. A [DATE] Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx which reached both the left and right buttocks. Resident 15's bed pan was changed to a fracture pan (has tapered end for easier placement). On [DATE] at 10:32 AM Staff 11 (RNCM) stated the fracture pan would need to be included somewhere to communicate to staff to use the fracture pan. Staff 11 stated she would check if the information was added somewhere in the documentation. No additional information provided the fracture pan was added to the care plan. | 2020-09-01 |