cms_OR: 9
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 740 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined the facility failed to assess and develop individualized interventions specific to expression of [MEDICAL CONDITION] for 1 of 1 sampled resident (#28) reviewed for behavioral-emotional health. This placed resident at risk for a decline in mood resulting in potential risk for reduced quality of life. Findings include: Resident 28 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The 12/9/18 Quarterly MDS under Section C: Cognitive patterns indicated Resident 28's BIMS (Brief Interview for Mental Status) score of 12 (8 to 12 indicates moderate impairment) and no mood or behavior concerns. Resident 28's Care Plan (revised on 4/5/18) addressed mood, included history of suicidal 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, medication per physician orders, mental health evaluation as needed, and to notify the DNS and/or Administrator at time of the incident after resident is safe. The 11/17/17 Suicide Ideation and Precautions Policy directed the interdisciplinary team to assess and develop interventions to address behavior. Resident 28's Care Plan had no individualized interventions or approaches to address the resident's suicidal verbalizations. Resident 28's current Visual/Bedside Kardex (system used by CNA staff to communicate important information) included no interventions to address verbalizations of suicidal ideation. 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. On 2/21/19 at 12:11 PM, Resident 28 was observed conversing with Witness 4 (Nurse Practitioner) in the fourth floor dining room stating she/he wished the staff had a gun to shoot her/him. In addition, Resident 28 stated she/he wanted an electric wheelchair to get run over with in the street. On 2/21/19 at 12:27 PM, Resident 28 was observed with Staff 23 (Pastoral Care) and Staff 24 (Receptionist) expressing she/he wanted to die. In an interview on 2/19/19 at 10:45 AM, Resident 28 stated that she/he wanted an electric wheelchair so she/he could get run over in the intersection. In an interview on 2/21/19 at 12:20 PM, Witness 4 (Nurse Practitioner), stated she worked with Resident 28 for the past two years and resident expressed [MEDICAL CONDITION] on multiple occasions. During an interview on 2/22/19 at 12:44 PM, Staff 16 (CMA) stated she didn't know what to do for Resident 28 and would like to see more things done to help her/him. In an interview on 2/22/19 at 3:30 PM, Staff 17 (CNA) stated that she would look for specific interventions on the care plan or kardex. She demonstrated where she would locate information in EHR (electronic health record) but was unable to locate individualized interventions for Resident 28. Staff 17 continued to state she thought Resident 28 was often attention seeking and she could change the subject. She stated Resident 28's suicidal verbalizations would not be urgent unless she/he had a knife or something. | 2020-09-01 |