| 10021 |
THE ARBORETUM AT THE WOODLANDS |
425394 |
50 ARBORTEUM WAY |
GREENVILLE |
SC |
29617 |
2011-04-26 |
323 |
H |
1 |
0 |
032B11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices for 4 of 11 residents reviewed for falls. Residents #1, #2, #3 and #5 had multiple falls and injuries without adequate interventions put in place to prevent further injury. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, "...Mental Status: Oriented x 2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation..." Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) score was 8. Observation of Resident #1 on 4/26/2011 at 7:20 AM, revealed the resident sitting on the side of the bed attempting to dress. Resident #1 had no alarms in place, no fall mats were seen and no wheelchair observed. A recliner with a manual footrest was observed. No lift chair was observed. Resident #1 also did not have a wheelchair. Observation of Resident #1's bathroom revealed bright red blood on the floor between the vanity and the toilet. The outside of the toilet bowl was smeared with bright red blood. The surveyor obtained staff assistance. Resident #1 stated that he fell this morning in the bathroom. The fall was reported to the CNA (certified nursing assistant) present in the room. Review of the Cumulative physician's orders [REDACTED]." Further review of the Cumulative Orders revealed the Chair Alarm was originally ordered on [DATE] and the Lift Chair was originally ordered on [DATE]. Review of the "Fall Risk Assessment" revealed only one entry dated 11/15/2011 that scored Resident #1 as a "6" indicating he was not at "High Risk" for falls. Review of the Nurse's Notes revealed the following entries: On 11/15/2010 at 12:30 PM, Resident #1 was found on the floor; a foam mattress was placed by the bed. On 11/16/2010 at 9:30 PM, Resident #1 fell and sustained a skin tear to the left forearm. It was noted that he was hanging clothes and slipped on a foam mattress. The foam mattress was removed. On 11/21/2010 at 9:30 AM, Resident #1 fell in the bathroom and sustained a laceration to the arm. On 11/23/2010 at 5:00 AM, Resident #1 fell on the floor in the room and sustained a rub burn to his/her knee. (A chair alarm was ordered per the telephone orders). On 12/8/2010 at 4:30 PM, Resident #1 fell in the bathroom and sustained a skin tear. On 12/10/2010 at 6:00 PM, Resident #1 fell in the bathroom and sustained a laceration to his head requiring sutures. (An order was written to send to the ER (emergency room ) status [REDACTED]. On 1/7/2011 at 9:30 AM, Resident #1 fell in the room no injuries were noted. On 1/9/2011 at 2:00 PM, Resident #1 fell in his room while trying to go to the bathroom. At 6:30 PM, Resident #1 fell again next to his recliner. (An order was written on 1/17/2011 for a "Lift Chair.") On 1/21/2011 at 6 PM, Resident #1 fell in his room and was found "scooting towards bathroom." On 2/11/2011 at 6 PM, Resident #1 fell in the bathroom. On 2/16/2011 at 9:45 PM, Resident #1 fell in the bathroom and hit his back on the shower bench. On 2/23/2011 at 4:20 PM, Resident #1 fell in the hallway no injuries were noted. On 3/3/2011 at 2:00 PM, revealed the following entry: "On February 16, 2011, this committee met to discuss new interventions that would decrease or prevent risk of falls. At this time the team implemented having a staff person assist resident to and from meals/walking. Resident's impulse control is effected due to [DIAGNOSES REDACTED]. Resident has difficulty at times standing from sitting down without dropping down. This is what seems to have the resident fall. Resident continues to walk with walker but does need some reminders. Resident is encouraged to call for assistance but is unable. The resident had been offered a chair alarm x 2 but declined. In 12/2010 a seat belt was offered and both resident and family declined. The resident is taken/asked every 1-2 hours for toileting needs but resident is continent and does not have a toileting pattern. Resident is also independent and becomes agitated at times when you offer assistance with bowel and bladder needs. Discussed the usage of a merry walker and at this time therapy could not see how this would work. Decided as a team to have resident use wheelchair for ambulation. Resident's family and resident are aware that resident is a fall risk any time he is up ambulatory and agreed that we should encourage the use of wheelchair. Family to bring wheelchair in from home. Care Plan revised." On 3/5/2011 at 12:15 PM, Resident #1 fell in the bathroom sustaining an abrasion to his right temple. On 3/10/2011, Resident #1 fell in his room. On 3/16/2011 at 5:15 PM, Resident #1 was found on the floor of his room with scalp laceration. The resident was sent to the emergency room for evaluation. On 4/1/2011 at 4:00 PM, Resident #1 fell in the bathroom. On 4/9/2011 at 12:30 PM, Resident #1 fell in the dining room. On 4/16/2011 at 9:30 PM, Resident #1 fell attempting to go the bathroom and sustained an abrasion to the right side of the face. On 4/24/2011 at 7:00 AM, Resident #1 was found on the floor in his room and had "hit his head." Review of the Incident Reports provided by the facility revealed the following: On 11/15/2011, the corrective actions taken to prevent further falls were "Resident unaware of safety measures due to disease process. Can ambulate safely once up from sitting position. At times resident may fall backwards. Resident refuses tab alarm due to the same agitation. Talked with family about helmet-family refuses. Family wants resident to remain independent with walking and states they are aware of the consequences." The incident report dated 11/23/2011 revealed the corrective action taken related was "encourage resident to take his time while attempting to get up out of chair." On 1/7/2011 the corrective actions taken were to "encourage resident to go slow when ambulating in room and to use walker at all times." On 1/9/2011 the actions taken to prevent further falls was to "attempt to check in more frequently. Hopefully he will allow is to keep his door open". The corrective actions taken for the second fall on 1/09/2011 were "reminded resident to call for assist, notified door would be left ajar while in room." On 1/21/2011, the corrective actions taken were to "remind resident to call for help-re-attach chair alarm." On 1/25/2011, the actions taken were to "monitor patient closely." On 2/12/2011, the corrective actions taken were "assisted resident in getting dressed and cleaning up his bathroom." On 2/16/2011, the corrective actions taken to prevent falls were "reminded to call for assist." On 3/5/2011, the actions taken were "will continue fall precautions." On 3/10/2011, the corrective actions taken were "patient is checked at least every 1-2 hours but due to dementia never asks for help rings call bell." On 3/16/2011, the summary of actions taken to prevent further falls was "pressure applied- call to doctor and family." On 4/1/2011, the actions taken were to "continue to check on patient every 1-2 hours for toileting." On 4/9/2011, the corrective actions taken were "instruct patient to call for assistance." On 4/16/2011, the corrective actions taken were to "monitor closely." No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area identified for "risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance." Added to the problem area was "risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker." The original date of the care plan was 11/30/2010 and reviewed 3/1/2011. Approaches included: "Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device." On 12/10 the care plan was updated with an approach to "observe resident at all times, remind resident not to throw clothes on floor." Chair alarm was added without a date and then crossed off due to "resident refused." In February 2011, the care plan was updated to include "OT (occupational therapy) in to work with resident and colostomy. Assist resident to and from meals." In March 2011, the care plan was updated to include "encourage use of wheelchair when ambulating (son to bring in)." Further review of the care plan revealed no evidence that the care plan was updated with the resident's numerous falls or that individualized interventions put in place to prevent further falls from occurring. During an interview with the surveyor on 4/26/2011 at 2:30 PM, Resident #1's son stated that he was aware of his father's multiple falls. He further stated that his father would not call for assistance. Resident #1's son stated that his father needed assistance with his colostomy and had requested the colostomy care be scheduled to reduce the risk of falls in the bathroom. He stated that his request was not followed and that the colostomy care was not scheduled. He further stated that he did attend a meeting regarding his father's falls and he stated that at no point during the meeting was a merry walker, seat belt or other type of device discussed. He stated that his father would routinely disconnect the alarms that were applied at one point. He also stated that he brought in his father's wheelchair from home, however, his father did not use it and he stated that no one in the facility encouraged its use. He also stated that he was never requested to take the wheelchair home and did not know where it was located. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) score was 4. Observation of Resident #2 on 4/26/2011 at 8 AM revealed the resident in the living room seated in a high backed wheelchair. A chair alarm was observed in place. The resident was noted to be unable to propel herself in the wheelchair. No seat belt was observed. A bed alarm was observed in the resident's room. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed the Safety Devices ordered were "seat belt and bed and chair alarms." Further review of the telephone orders revealed the original order for the bed and chair alarms was 1/11/2011. The original order for the seat belt was 3/3 for a trial of the seat belt then 3/8/2011 the seat belt was ordered. On 4/25/2011 a telephone order was written to "d/c (discontinue) the seatbelt - ineffective broken x 2." Resident #2 was noted to receive Hospice Care due to a rapid decline in April 2011. The primary [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 11/29/2010 (a previous admission) that scored the resident as a "5" indicated she was not at high risk for falls. Review of the Nurse's Notes revealed the following entries: On 1/9/2011 at 5:20 PM, Resident #2 fell in hallway and sustained a laceration to her head and bruising. On 1/16/2011 at 10:30 AM, Resident #2 fell in room while attempting to toilet self. On 1/20/2011 at 3 PM, Resident #2 fell to her knee, no injuries. On 1/24/2011 at 12:30 AM, the resident fell out of bed and abraded her/his back. On 1/26/2011 at 2:50 AM, Resident #2's bed alarm sounded and the resident was found on the floor. On 2/8/2011 at 8 PM, Resident #2 was found on floor by bathroom, she sustained a skin tear and a hematoma to the left hip. On 2/26/2011, Resident #2 fell and was found unresponsive with pupils fixed. On 3/2/2011 at 1 PM, Resident #2 was found of floor beside bed. On 3/3/3011, "meeting held with MDS coordinator, DON, Activities, and Physical Therapist to discuss resident's falls. Care Plan for falls reviewed at this time to discuss interventions." On 3/8/2011 at 2:15 PM, the resident fell in the living room and sustained a bump on the head. On 3/21/2011 at an unknown time, the resident was found on the floor with the chair alarm sounding. On 3/27/2011, the resident was found on the bathroom floor. On 4/15/2011 at 9:30 AM, the resident was found on the floor of the bathroom with the chair alarm sounding. On 4/18/2011 at 8 PM, Resident #2 fell out of the wheelchair and sustained an abrasion to her back. On 4/25/2011 at 9:40 PM, Resident #2 fell out of bed and sustained an abrasion to her nose. Review of the Incident Reports provided by the facility revealed the following: On 1/9/2011 the corrective action taken to prevent further falls was "close monitoring." On 1/16/2011 the corrective action taken was to "encourage resident not to get out of wheelchair without assistance, resident has fallen previously and has had a cognitive decline." On 1/20/2011, the alarm appropriately sounded and the corrective action taken was to "remind resident to ask for assist with transfers and to keep patient close to nursing station." On 1/24/2011, the bed alarm sounded appropriately and no corrective action was documented. On 1/26/2011 the bed alarm sounded appropriately and the corrective action taken was "encouraged resident to utilize call light when toileting is needed. Call light in reach and resident oriented to proper use." On 2/8/2011 there was no indication of any alarm. The corrective action taken was for the resident to "call for help and using the call bell." On 3/2/2011 there was no indication that the alarm sounded. The corrective action taken was "transferred to common area and needs more frequent monitoring." On 3/8/2011, there was no indication that the resident had a seatbelt in place and the corrective action taken was "will try to monitor further and more often" and "patient is scheduled to receive a belt for wheelchair." On 3/21/2011, there was no indication that a seatbelt was in place or that the alarms sounded. The corrective action taken was for the resident to "comply with instructions to call for help. Have staff check every 1-2 hours." On 3/27/2011, there was no indication that the resident's alarms sounded or that the seat belt was in place. The corrective actions taken were to "continue bed alarm, chair alarm, low bed, seatbelt." On 3/30/3011, the resident's alarm appropriately sounded and the resident had unfastened the seatbelt. The corrective action taken was "resident will not comply to instructions related to safety seat belt. Will continue to monitor, will continue to assess resident for pain, will continue to apply alarms, will continue to encourage resident not attempt to get up out of wheelchair." On 4/9/2011 the bed alarm sounded appropriately. The corrective actions taken were "continue bed alarm and low bed." On 4/15/2011, the corrective actions taken were "will check patient even more frequently than usual due to Urinary Tract Infection." On 4/18/2011, the corrective actions taken were "assessment done, v/s (vital signs) taken, continue chair and bed alarm and low bed." On 4/25/2011, the corrective actions taken were to "continue low bed with bed alarm." Review of the Care Plan revealed a problem area identified related to "Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications. The care plan was dated 1/7/2011 and was reviewed on 2/8/2011, 2/16/2011 and 3/3/2011. The approaches included: "encourage use of assistance device, PT/OT (physical therapy/occupational therapy) evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. The care plan was updated on 1/7/2011 to include "bed/chair alarm at all times" and "observe resident frequently related to attempts to ambulate without assist." On 3/8/2011 the care plan was updated to include "Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised." There was no indication the care plan was updated with appropriate interventions to prevent further fall. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Observation of Resident #3 on 4/26/2011 at 8:40 AM, revealed the resident was in the dining room seated in a wheelchair. A chair alarm was observed in place. The resident was noted to self propel himself. Observation of the resident's room revealed Resident #3 had a bed alarm in place. The bed was note against a wall. One fall mat was observed folded in half and stored against the wall. A lift recliner was observed. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed no orders for any type of alarm, fall mat, recliner etc. Review of the Falls Risk Assessment revealed one entry dated 7/19/2010 that scored Resident #3 as a "16" indicating he was at "high risk" for falls. Review of the Nurse's Notes revealed the following entries: On 11/20/2010 at 10 PM, the resident was found on the floor beside wheelchair. On 11/22/2010 at 11:50 AM, the resident was found on the floor at the end of the bed scooting towards the door. 11/23/2010 at 3:20 AM, the resident was found on the floor attempting to urinate. On 11/24/2010 at 2 AM, the resident was found on the floor and stated that he was taking a walk and fell . On 11/25/2010 at 10:15 AM, the resident was found on the floor. On 11/29/2010 at 9 PM, the resident was found sitting on the floor. On 12/3/2010 at 2:55 AM, the resident was found sitting in the floor. At 8:45 AM, the resident was found sitting "Indian style on bathroom floor." At 2:30 PM, the resident was found sitting on the floor in front of recliner. On 12/10/2010 at 4:30 AM, the resident was found sitting in his room beside the bed. At 10:35 PM, the resident was found on the floor by his dresser. On 12/13/2010 the resident reported pain in the right wrist. X-rays were obtained and were positive for a wrist fracture. On 12/15/2011 at 8:15 PM, the resident was found on the floor. At 9:20 PM, the resident was found on the floor at the head of the bed. On 12/20/2010 at 7:45 PM, the resident was found on the floor by the dresser. On 1/10/2011 at 4:30 AM, the resident was found on the floor by the bed. On 1/11/2011 at 7:25 PM, the resident fell out of the wheelchair attempting to adjust his socks. On 1/21/2011 at 11:30 AM, the resident was noted to be lying on the floor in his room. On 1/26/2011 at 7:30 PM, the resident was noted on the floor. On 2/23/2011 at 1:40 PM, the resident "repeatedly rolled forward out of wheelchair sounding the chair alarm." On 3/5/2011, 9:10 PM, the resident was found sitting on floor with legs folded, sitting on feet. At 9:20 PM, the resident was found again on the floor with legs crossed. On 3/6/2011 at 9 PM, the resident was found sitting on the floor with legs crossed. On 3/14/2011 at 12:50 AM, the resident's bed alarm was sounding; the resident was found on the floor with his head on the ground. Abrasion to right forehead noted. On 3/25/2011 at 11:20 AM, the resident's chair alarm was sounding and the resident was found on the floor in front of the wheelchair. On 4/6/2011 at 11:50 AM, the resident was found on the floor in front of the wheelchair, buttocks and coccyx reddened. On 4/19/2011 at 6:45 PM, the resident was found on the floor in the hallway in front of the wheelchair. An abrasion was noted to his forehead. 4/21/2011 at 6:40 AM, the resident was lowered to the floor by a CNA after a transfer to the wheelchair. On 4/22/2011 at 2:30 PM, the resident rolled off low bed and onto low mat, the resident was noted crawling around room. At 9:50 PM, the resident was on left side of mat on left elbow. Review of the Incident Reports provided by the facility revealed the following: On 11/20/2010, there was no documentation of alarms and no documentation of corrective action taken to prevent further falls. On 11/20/2010, there was no documentation of alarms or no documentation of corrective action taken. On 11/22/2010 there was no documentation that the alarms were sounding and the corrective action was "reminded to call for assist." On 11/14/2010 there was no documentation that the alarms sounded and the corrective action was "resident is on low bed with mats, in the past he has admitted to deliberately putting himself on the floor from the bed. This is a recurring behavior and it is unsure if this is a true fall. Intervention low bed and mat continues. Have tried tab alarms x 2 in the past but resident has destroyed them beyond repair." On 11/29/2010 there was no documentation that the alarms sounded and the corrective action taken was "is on low bed with mats, refuses tab alarm." Another corrective action was "may need to move room to closer to nurses desk, questionable 1:1 care, continue to encourage to ask for help with assist." (The resident's room did not change nor was he ever placed on 1:1 care). On 1/10/11 there was no documentation that the alarm sounded, the resident sustained [REDACTED]. There was no corrective action documented. On 1/11/2011, the corrective action taken was "nursing assessment completed assisted back to chair, monitored. Encourage resident to ask for help when reaching towards shoes, ground etc. Understood by resident." On 1/21/2011, the corrective action taken was "chair alarm in place, will follow up with doctor regarding lab results for possible reasons for decreased pulse." On 1/26/2011 there was no documentation that the alarms sounded, the corrective action taken was "we'll monitor closely, needs to be more often at common areas for monitoring." On 2/23/2011, the alarms sounded appropriately, the corrective action taken was "encouraged to ask staff for assistance" and "proper use of chair alarm, resident non compliant." On 3/5/2011, there was no documentation that the alarms sounded, the corrective action taken was continue low bed, bed alarm." On 3/5/2011, the bed alarm sounded and the corrective action taken was to "continue low bed with bed alarm." On 3/6/2011, the bed alarm sounded and the corrective action taken was "will keep resident up until Trazadone given." On 3/14/2011, the bed alarm sounded appropriately, the corrective action taken was "Neuro checks due to small abrasion on forehead." On 3/25/2011, the alarm sounded appropriately, the corrective action taken was "resident unaware of own limitations, refuses to follow instructions to call for help when assistance required. Performed Body Audit, v/s, assessed for pain, notified nurse practitioner. Will continue with chair and bed alarm and will continue to assess for pain. On 4/6/2011, there was no documentation the alarms were sounding, the corrective action taken was "will keep trying to have patient involved with activities in living room where can be supervised. All safety measures are being used as able." On 4/6/2011 the corrective action taken was "all precautions devices in use" and "resident needs to call for help." On 4/19/2011, there was no documentation that the alarms were sounding; the resident sustained [REDACTED]. The corrective actions taken were to "continue with chair alarm." On 4/22/2011, there was no documentation that the alarms were sounding, the corrective action taken were "will continue bed and chair alarm." No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area related to "risk for further falls/injury." The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. "Continues to roll self out of bed without injury. Resident aware of rolling from bed. A Bed pad alarm tried prior to readmit, resident destroys alarms." On 12/1/2010, the care plan was updated with "will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include "encourage resident to remain in common areas when out of bed." On 12/5//2010, the care plan was updated to include the same approach of "encourage resident to remain in common areas when out of bed." On 12/10/2010, the care plan was updated to include "observe resident frequently when in room or out of room." On 12/14/2010, the care plan was reviewed and included the following: "Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms." The care plan was not adequately updated with appropriate interventions to prevent further falls/injuries. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Observation of the Resident #5 on 4/26/2011 revealed the resident in the commons area seated in a wheelchair, a chair alarm was present. Observation of the resident's room revealed a bed alarm on the night table. Review of the Cumulative physician's orders [REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 9/13/2010 that documented the resident's score as a "14" indicating she was at "high risk" for falls. Review of the Nurse's Notes revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. No Incident Reports were provided at the time of the survey for Resident #5. Review of the Care Plan revealed a problem area identified related to "Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to "continue with current problem." The care plan was reviewed again on 3/2/2011. Approaches included: "walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance." On 10/11/2010, Resident #5's care plan was updated to include the following approach: "Remind resident not to stand without assist. Keep resident in common area when out of bed." There was no evidence that Resident #5 had adequate interventions put in place to prevent further falls/injuries from occurring. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. The DON also confirmed the Falls Risk Assessments were not current and were not accurate for all residents. She stated that there was not a facility policy related to the assessments but stated that she expected the assessments to be completed after each fall. The DON stated that Resident #1 was not alert and oriented and was not able to make his own decisions. The DON also confirmed the actual harm and injuries sustained by Residents #1, #2, #3 and #5 related to falls and they had noticed an increase in the number of falls. The DON stated that a new Medical Director had just started but that no actions had been put in place. During an interview with the surveyor on 4/26/2011, the Medical Director stated that he started on 4/16/2011. He stated that he was not aware of the high number of falls. He stated that he had not yet attended a Quality Assurance Committee. |
2014-08-01 |