| 8232 |
WINDSOR MANOR |
425114 |
5583 SUMMERTON HIGHWAY |
MANNING |
SC |
29102 |
2013-06-06 |
280 |
E |
1 |
0 |
43K911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise the plan of care for Resident # 51 related to repeat falls and multiple use of restraints. The plan of care did not accurately reflect the interventions used. (1 of 4 sampled residents reviewed for falls and 1 of 3 sampled residents reviewed for restraints and the revision of the plan of care. ) The findings included: Resident # 51 was admitted to the facility on [DATE]. Record review on the days of the survey revealed the resident had multiple falls, with and without injury, and multiple restraint devices had been attempted. On 6/5/13, review of the two careplan's (Admission and quarterly) completed for the resident revealed the following concerns: Padded siderails that were discontinued on 12/12/12 continued to be listed on the plan of care Provide Broda chair for locomotion (discontinued 5/15/13), remained on the careplan The use of a Geri chair with a table (12/20/12), abdominal binder (12/23/12), reclining chair (12/19/12), Broda chair with leg restraints (discontinued 1/28/13 ) were not noted on the careplan. The residents unsafe behaviors of climbing over the siderails, sliding under the waist restraint and trying to slide the restraint over his/her head were not addressed. The last fall recorded on the careplan provided for review on 6/5/13 was 5/1/13 which stated send to ER (emergency room ) for evaluation as ordered Record review indicated the resident either fell or was found on the floor on 5/18,5/20,5/27/13. There was repeated documentation of the resident pulling out or otherwise tampering with his/her feeding tube. The concern nor preventives measures were not included on the plan of care for the feeding tube. The resident was assessed as being unable to use the call light system and was documented as having severe cognitive impairment with a BIMS (Brief Interview Mental Status) of 5. However, careplan approaches included the following: answer call light promptly, keep call light in easy reach, allow resident to make as many choices as possible, encourage resident to report to nurse if feels upset, angry, encourage resident to express fears and concerns, provide clock (clock in residents room over doorway was non functional), instruct resident on how to use call bell, give resident update on news 2 times a week. Under the fall prevention careplan it was noted that the same approaches were used including use diversional activities, continues low bed and mat on floor, continue Broda chair, continue to encourage resident to ask for assistance and use call light re-instructed resident to use call light for assistance, continue low bed, alarming pad, bed/chair alarm, Broda chair. On 6/6/13 at approximately 8:30 AM an interview with the Care Plan Coordinator was conducted. S/he stated s/he had assumed careplan duties on 3/4/13 at the facility. S/he stated the careplan were not to his/her liking. S/he verified the use of inappropriate and repeated approaches, missing falls and all the restraint devices that were used were not included in the plan of care. When asked how Certified Nursing Assistants would know the type of care a resident required, s/he stated the information was provided in daily report and although unlikely, the CNA's could always look at the plan of care. At that time, s/he confirmed how Resident # 51 transferred was not listed on the careplan. The MDS (Minimum Data Set) assessment indicated the resident was transferred with assistance of one, the Unit Manager when asked, stated s/he would like the resident transferred with assistance of 2. Both types of transfers were observed during the days of the survey. |
2016-06-01 |