cms_OR: 8959
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8959 | HOOD RIVER CARE CENTER | 385104 | 729 HENDERSON ROAD | HOOD RIVER | OR | 97031 | 2011-07-27 | 281 | G | 1 | 0 | 0FG111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to follow professional standards for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a left [MEDICAL CONDITION]. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] (6) (d) Follow the care plan as directed by the licensed nurse; (f) Tasks associated with safety; (B) Apply preventive/supportive/protective strategies or devices when working with a person with dementia. Conduct Unbecoming a Nursing Assistant [PHONE NUMBER] (2) (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant. Resident 1 was admitted to the facility in late January 2011 with [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-[MEDICAL CONDITION] agents) for polymyalgia rheumatica and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in lowest position and mats on both sides of the bed. Review of the resident's clinical record revealed a history of falls from her/his wheelchair. The care plan was updated on 6/24/11 and included, "Do not leave the resident alone when in the W/C (wheelchair)." An IR (Incident Report) on 7/15/11 revealed the resident was placed in a shower chair and taken to the shower area in the bathroom in her/his room by Staff 2, CNA. Staff 2 noticed a puddle of urine just outside the bathroom door. The IR revealed Staff 2 reached for paper towels and placed them on the urine and wiped the floor with her foot. Staff 2 reported she heard a thump and noted the resident was against the wall on her/his left side, hit her/his head on the wall and had slid to the floor. The conclusion of the investigation revealed, "Aide made an error in judgment by turning away to wipe up fluid on the floor when with high risk patient." The resident was transported to a local hospital ER and found to have sustained a left [MEDICAL CONDITION]. The hospital reports revealed the resident had a surgical repair of the fracture on 7/15/11. In interview on 7/26/11 at 11:10 am, Staff 2, stated she was aware the resident was at high risk for falls. A re-enactment of the event was done with Staff 2. She stood in the doorframe of the bathroom and stated it was at that point the resident was no longer in view and not within arms reach. "I was aware I should have kept (her/him) in view and in close contact at all times." In interview on 7/26/11 at 11:25 am, Staff 3, CNA, stated she assisted in the transfer of the resident to the shower chair on 7/15/11. She reported the resident was placed as far back as possible in the shower chair as she/he was such a high fall risk. In interview on 7/26/11 at 11:50 am, Staff 4, RN, stated he was summoned to the resident's room at approximately 10:00 am on 7/15/11. He stated he observed the resident on the floor in the shower. Staff 4 stated the resident's left leg was pronated and a large hematoma of the left hip had formed in approximately 10 minutes. He stated the resident did not complain of any pain. The EMS was activated and the resident was transported to a local hospital ER. He stated, "The aide cleaned up a spill and placed the resident at risk to do so." The 7/21/11 hospital discharge summary revealed the resident had passed away. The report revealed, "The reason for (her/his) expiration is felt to be a combination of (her/his) recent [MEDICAL CONDITION], significant dementia, [MEDICAL CONDITION] and possible underlying lung disease." Refer to F 323 | 2014-11-01 |