| 7706 |
LINVILLE COURT AT THE CASCADES VERDAE |
425392 |
30 SPRINGCREST COURT |
GREENVILLE |
SC |
29607 |
2013-05-09 |
323 |
G |
0 |
1 |
07OZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and review of the facility's policy entitled Falls Management, the facility failed to provide sufficient and effective fall prevention interventions for 1 of 3 residents with falls. Resident #68 had 10 falls prior to the days of the survey and 1 fall during the survey without new interventions put in place or evidence of reviewing the interventions that had been put in place, resulting in additional falls for Resident # 68. Cross refer to F 280 related to the failure of the facility to review and revise the careplan for Resident # 68 related to falls. The findings included: Resident #68 was admitted with [DIAGNOSES REDACTED]. Record review on 5/8/13 at 1:25 PM revealed a Fall investigation Worksheet that documented the resident had a fall on 4/25/13 at 2000 (8:00 PM). The report also stated that the resident had 3 falls in the last 30 days and 7 in the last 31-180 days. Review of the resident's Nurses Notes indicated that the resident had 10 falls since admission. The resident also had a fall during the days of the survey. When the surveyor asked for incident reports/fall investigations, the facility provided only seven (7) reports. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. The Nurse's Notes revealed the following falls : 1. 2/19/13 at 1550 (3:50 PM), fell out of wheelchair, denied pain, bruising noted to left hip. 2. 2/20/13 at 1700 (5:00 PM), noted sitting on floor on mat in kneeling position, no injury. 3. 2/22/13 at 2230 (8:30 PM), sitting on floor beside bed, minor bruise rear, upper left thigh, mat in place, not witnessed. 4. 3/8/13 at 1700 (5:00 PM), got out of wheelchair, fell , found lying on left side, no injuries noted. 5. 3/8/13 at 2300 (11:00 PM), found sitting on floor on mat beside bed, no signs of injury. 6. 3/12 13 at 1530 (3:30 PM), lying on floor on knees, no injury noted. 7. 4/1/25 at 7:55, alarm sounding, resident on mat on knees, no injuries noted. 8. 4/9/13 at 1730 (5:30 PM), the resident was observed sitting on blue mat on floor, no injury noted. 9. 4/18/13, found lying on right side at 4:00 PM, wheelchair alarm sounding, laceration to right eyebrow, abrasion to right upper cheek, skin tear to right elbow, bruise to right knee. 4/19/13, PT consulted for wheelchair positioning. 10. 4/25/13 at 3:45 PM, found lying in floor mat on floor, alarm sounding, no injury noted. The Fall Risk Assessment and Interventions for the resident were dated 2/5/13 and 4/25/13. On 2/5/13 the resident was assessed as a 32 on the scale which indicated s/he was a high risk for falls and on 4/25/13 a 30. The scale indicated that 7 or higher was a high risk. No interventions were documented on the assessment. The incident reports provided by the Interim Director Of Nursing indicated that on: 2/29/13 the alarm box was turned off but sounded at the system. The fall occurred in the resident's room at 3:50 PM with no apparent injury. Steps taken were noted as notified maintenance of late alarming, rechecked proper functioning and placement. 2/20/13 at 4:45 PM, the incident occurred in the resident's room. There was no injury and the alarm was functioning properly. Steps taken to prevent recurrence were more frequent checks for 72 hours, post fall follow up. 3/8/13 at 5:00 PM, the incident occurred in the dining area and no alarm was in place. No injury noted and the alarm was placed on the resident. Steps taken to prevent recurrence were alarm placed. 3/8/13 at 8:13 PM, the fall took place in the resident's room. No injuries were noted. Bed alarm did not sound. Steps taken were rechecked bed alarm is attached and functioning. 4/1/13 at 7:55 PM, the incident occurred in the resident's room. The report stated that the alarm was sounding, the resident stated that he/she was going to the bathroom and the resident had no injury. Steps taken were to assist resident to bathroom and toilet more frequently. 4/18/13 at 3:20 PM, indicated that the incident occurred in the day room. The presence of the alarm was not noted on the report and the steps taken were to refer to physical therapy for a possible chair change. The resident was noted to have a laceration to his/her right eyebrow, multiple abrasions to the right upper cheek and a skin tear to the right elbow. 4/25/13 at 3:34 PM the fall occurred in the resident's room. The alarm was sounding. No injury was noted. The steps taken were refer to therapy for pool therapy for decreased anxiety and strengthening. 5/8/13 at 2045 (8:45) PM the incident occurred in the resident's room. He/she had a skin tear to the left elbow and to the right shin. The steps taken were scoop mattress, refer to wellness for ambulation and 1:1. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. Review of the resident's admission Minimum Data Set revealed that the resident had a fall history prior to admission and a BIMS score of 1 (one) indicative of cognitive impairment. Review of the resident's care plan indicated that the fall on 4/25/13 was not on the care plan. The care plan also indicated that there were no new interventions added for each fall and no evidence of evaluation for the interventions which were in place. Review of the physician's telephone orders indicated that an order for [REDACTED]. PT notes reviewed for 3/27/13 through 4/27/13 indicated that resident was admitted to PT for gait training and strengthening. The summary indicated that the resident was at risk for falls and further decline with increased dependency on caregivers. The documentation for 4/29/13 through 5/23/13 indicated that on 3/27/13 the resident still had potential for improvement. On 4/26/13 the resident was placed in a Broda Chair and provided services for positioning. The intervention was documented on the back of a falls investigation work sheet on 4/18/13. In an interview with the Physical Therapist, she/he stated that it took a while to get the chair due to medicare not covering the cost and they had to wait until they could reach the family to get approval for the chair. Review of the Physician's Monthly Orders indicated that the resident was to have a bed and chair alarm. Review of the Treatment Administration Records for March, April and May of 2013 indicated that the staff had checked the resident's alarms and that the alarm was in place and functioning properly on the days that the falls occurred. 5/8/13 at 2:20 PM, during an interview with the Interim Director of Nursing, she/he stated the facility did not have a formal fall committee and all falls are reviewed at the morning meetings. S/he also stated that the facility does not use restraints or self release belts. On 5/10/13 at approximately 2:45 PM, during an interview with the physician, she/he stated that she/he was not aware that the resident had had that many falls or the circumstances of the falls. She/he stated that the 9:00 PM dose of Seroquel had been decreased from 25 mg to 12.5 mg and changed from 9:00 PM to 4:00 PM. The physician stated that the staff should be mindful of when alarms were going off and put more staff into place. She/he noted the facility had used a lot of agency staff lately. Review of the facility's policy entitled Falls Management revealed Policy: Patients will be assessed for falls risk as a part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury .Practice Standards .3. Develop individualized plan of care. 4. Review and revise care plan regularly . 5.3.2 Resident/patient Incident Report . |
2016-12-01 |