| 51 |
CHERAW HEALTHCARE |
425005 |
400 MOFFAT ROAD |
CHERAW |
SC |
29520 |
2019-10-17 |
600 |
D |
1 |
0 |
NNBR11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility staff failed to ensure 1 of 24 sampled residents (Resident #17) was free from possible neglect. On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 turned the resident onto her side but failed to ensure the resident was safe from falling. As a result, Resident #17 fell from the bed and struck her head on the corner of a chair that was sitting next to the bed. The resident sustained [REDACTED]. The findings included: Review of the facility's policy entitled Perineal Care (Peri-care) (undated) revealed the following: Purpose: 1. To cleanse the perineum; 2. To prevent infection and odors. Equipment: 1. Soap and water; 2. Bath basin; 3. Washcloths and towel. Procedure: 1. Explain procedure to the resident and bring equipment to the bedside; 2. Provide privacy for the resident; 3. Assist the resident to void first if they need to; 4. Do perineal care at least one time a day with bath and PRN (as needed); 5. Cleanse the area with warm water and soap. When washing the area, always wash from the front to back (sic). Be careful not to pull the washcloth from the anal area to the vaginal area; 6. Rinse the area; 7. Towel blot dry the area; 8. Assist the resident to a comfortable position; 9. Return equipment to its proper area; 10. Wash hands; 11. Chart care rendered. Notify the appropriate person of any abnormal findings. The policy did not address adjustment of residents' bed heights, or the use of side rails during peri-care. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one (1) staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one (1) staff person for transfers and had impairment to one (1) side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Monitor for safety and maintain safe environment; 2. Assist as needed in all ADLs (activities of daily living) areas; 3. Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; 4. Encourage to wear shoes with non-slip soles; 5. Maintain bed in low position while not rendering care. 6. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; 7. Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; 8. Notify Responsible Party and MD of all fall instances; 9. Monitor for s/sx (signs/symptoms) of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; 10. Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; 11. Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and 12. Administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Provide routine oral hygiene; 2. Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; 3. Offer toileting assistance every two hours and as needed in an effort to maintain some continence; 4. Provide incontinence skin care daily and as needed; 5. Turn and reposition every two (2) hours and as needed while in bed; 6. Transport to specific destinations once up; 7. Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; 8. Provide showers three (3) times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; 9. Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; 10. Transfer from bed to geri-chair as tolerated; and 11. Perform treatments per MD orders. Review of Resident #17's Progress Notes revealed the following: 7/7/19 - Resident #17 Quietly resting in bed with eyes closed. (No added distress) NAD noted. Resp(irations) even and nonlabored. Total dependent care by staff. Kept clean, dry and comfortable in bed. 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of Resident #17's Radiology report dated 7/13/19 revealed the resident's left shoulder was x-rayed and compared to an x-ray completed 12/12/17. According to the comparison there was no change in resident's status since prior x-ray. Results: Impacted fracture involving the humeral neck. The acromioclavicular and coracoclavicular joints are intact. Conclusion: Impacted humeral neck fracture (present prior to the fall from bed). The report also noted no fracture to the resident's left elbow. Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. According to the report, CNA #6 had Resident #17 facing her while the staff performed incontinent care, but when the aide moved to reach for the diaper located at the foot of the resident's bed, Resident #17 suddenly flipped over causing her to hit the left side of her face on the chair which was beside her bed then fell to the floor. Bed was in low position. Interventions by facility to prevent future injury/Alleged Abuse: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper, she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN (Registered Nurse) #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. Review of CNA #6's Employee file revealed the Aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence. The document noted the following: Negligence in assigned duties or overall resident care. CNA failed to follow proper turn and reposition. Not making sure resident is in the center of the bed before turning and repositioning. CNA was in-serviced 1:1 on turning and repositioning with charge aide. If it happens again - will terminate. The form was executed by both the Director of Nursing (DON) and the Assistant DON (ADON). The form noted that CNA #6 Refused to sign the document. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a Geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. The resident was able to nod yes or no to direct questions. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed that CNA #2 escorted Resident #17 to her room in order to transfer the resident from her Geri-chair to her bed. CNA #2 completed a one-person pivot transfer and placed the resident in the center of her bed, elevated the head of Resident #17's bed and then placed the bed in a low position. The transfer was completed safely without incident or injury. Interview on 10/15/19 at 10:47 a.m. with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor and positioned between the two (2) beds in the room. CNA #1 said that when she entered the room, she saw that Resident #17's bed was not in a low position and neither side rail was raised. CNA #1 explained that when providing resident care and moving residents from side to side, aides were to raise the side rail so that residents could hold onto the rails during care. CNA #1 said Resident #17 was not able to independently roll from side to side while in the bed. She said the resident was total assist and required assistance from staff to move in the bed. She said she did not understand how the resident could have rolled from bed. According to CNA #1, CNA #6 told her that while she (CNA #6) was providing care for Resident #17, she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. When asked about the position of residents' beds during peri-care, the ADON said the aides were to adjust residents' beds to a comfortable height in order to provide care. Upon completion of care, aides were to place the beds back in a lower position. The ADON said CNA #6 reported to her that Resident #17 was on her back and that when CNA #6 went to grab a diaper on the wheelchair, Resident #17 fell from the bed. The ADON said CNA #6 was written up because she performed peri-care incorrectly. The ADON said the resident's fall was not identified as a possible incident of neglect. Further interview revealed that CNA #1 told the ADON that she believed Resident #17 was too close to the edge of the bed, and that was the reason the resident fell . Telephone interview on 101/17/19 at 4:38 p.m. with RN #2 revealed the nurse did not recall well Resident #17's fall from bed during peri-care. RN #2 said the incident was so long ago. RN #2 said she did remember that CNA #6 told her that she (CNA #6) pulled Resident #17 towards her (CNA #6) and when she did this, Resident #17 slipped between her and the bed. RN #2 said she did not recall CNA #6 saying that she was reaching for a diaper (incontinent brief). RN #2 continued and said that she did not think CNA #6 could have done anything differently to prevent the incident from occurring. RN #2 said possible neglect was not considered because if CNA #6 had required more assistance to complete peri-care, then the aide would have asked her co-workers for help. The RN said it was possible for that type of thing to happen. |
2020-09-01 |