| 8234 |
KINGSTREE NURSING FACILITY |
425117 |
401 NELSON BOULEVARD |
KINGSTREE |
SC |
29556 |
2013-06-07 |
280 |
E |
1 |
0 |
8GKN11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification and complaint surveys, based on record review and interviews, the facility failed to ensure that the care plan was reviewed and accurately updated to concur with physician's orders [REDACTED]. The facility failed to update the care plan for Resident #20 to consistently provide interventions to minimize injury in the event of falls. The findings included: On 9-19-12, an Initial 24 Hour Report was received by the State Agency related to an injury of unknown origin or possible abuse. Resident #20 sustained a hematoma to the right forehead, right side of the head, and behind the right ear, which had been reported to facility staff by a Hospice Certified Nursing Assistant (CNA) at 8 AM that morning. The physician and family were notified and the resident was sent to the hospital for evaluation and treatment. An investigation was begun and the Kingstree Police Department was notified. Review of the facility's Five-Day Follow-Up Report dated 10-1-12 revealed that the Hospice CNA noted blood in the resident's hair on 9-19-12 while in the shower. S/he noted a bruise and notified Licensed Practical Nurse (LPN) #1 who checked the resident and found her/him with a second area of bruising as well. The physician and family were notified in a timely manner and the resident was transported to the emergency room for evaluation. An investigation was conducted immediately including staff and resident interviews. No blood was found in the shower or resident's room. No falls were reported or heard on the 11-7 shift on 9-18-12. At change of shift, neither the 11-7 nor 7-3 CNA noted any injury. The 7-3 nurse (LPN #1) and CNA #1 observed the resident being ambulated to the shower with no evidence of injury. Facility staff was unaware of any injury until the Hospice CNA called for the nurse's assistance related to a [MEDICAL CONDITION] and hematoma. During interviews, the Hospice CNA denied any occurrence in the shower. The facility was unable to substantiate abuse. Review of the medical record on 5-3-13 revealed that the facility admitted Resident #20 on 5-7-12 with [DIAGNOSES REDACTED]. Review of the 5-16-12 Admission Minimum Data Set (MDS) and the 8-12-12 Quarterly MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident's cognitive function was severely impaired. The Quarterly MDS noted her/him as totally dependent for dressing, toileting, hygiene, and bathing. Bed mobility and eating required extensive assistance. Balance was steady. There was no limitation in range of motion. Multiple falls were coded on both assessments. Transfers and ambulation required supervision only. Behaviors initially included inattention, disorganized thinking, and wandering. The Quarterly assessment added behavior directed at others. Incident Reports from admission to 9-19-12 were requested at 12:55 PM on 5-3-13 and supplied by the Director of Nurses for review at 2:30 PM. Review of the Incident/Accident Reports and Nurse's Notes revealed the following. (1) On 5-8-12, the resident fell in the hallway in the process of attempting to pick up items from the floor. A laceration/contusion above the right eye was treated with first aid. The physician and family were notified in a timely manner. Redirection and 1: 1 activity was provided. (2) On 5-9-12, the resident attempted to sit on the elevated legrest of a gerichair and fell to the floor. First aid was administered to a laceration/ abrasion on the right ear. The physician and family were notified in a timely manner. On 5-9-12, a gerichair was ordered as needed for rest periods and [MEDICATION NAME] was discontinued. Trazadone 100 mg (milligrams) was ordered at bedtime for restlessness/sleep on 6-6-12. (3) On 6-23-12, the resident pushed away from another resident in the day room, stumbled backward and sat on the floor. First aid was administered to a hematoma. The physician and family were notified in a timely manner. On 6-25-13, Trazadone was increased to 150 mg daily [MEDICATION NAME] mg was added at bedtime. (4) On 6-26-12, the resident was noted sitting on the floor in her/his room. S/he was transported to the emergency room complaining of hip pain. The physician and family were notified in a timely manner. After the resident returned from the hospital, a physician's orders [REDACTED].[MEDICATION NAME] Trazadone administration times were adjusted to be given after the evening meal instead of at bedtime. On 6-27-12, an order was written to wear soft helmet at all times. A low bed and mats were ordered as well (5) On 6-27-12, the resident was noted on the floor in the dayroom. First aid was applied to a skin tear on the left cheek and top of left hand. A soft helmet was in place. The physician and family were notified in a timely manner. On 7-1-12, a sensor pad was added to the low bed. On 7-2-12, gerisleeves were ordered, to be worn as tolerated. On 7-2-12, the resident was sent to the emergency room for evaluation due to a (nonspecific) change in mental status. Bactrim DS was ordered for 7 days for a Urinary Tract Infection. A CT scan of the head was done which showed no intercranial hemorrhage, fracture, or mass effect. Diffuse deep white matter changes. On 7-3-12, the resident was transferred to room [ROOM NUMBER]A, closer to the nursing station. On 7-6-12, evening medication time ([MEDICATION NAME]) was changed to 7 PM. (6) On 7-9-12, the resident attempted to sit on the couch in the dayroom, but slid to the floor. No injuries were noted. The physician and family were notified in a timely manner. A Physical Therapy referral was done, the physician was requested to review the medication regimen, and a UA (Urinalysis) C (ulture)&S (ensitivity) was collected (negative report 7-12-12). (7) On 7-9-12 at 4:15 PM, the resident was noted lying on the floor by the sofa where s/he had been sleeping. No injuries were noted. The resident was toileted and required 1:1 supervision because of continued walking. The physician and family were notified in a timely manner. The physician ordered [MEDICATION NAME] 0.25 mg to be given twice daily as needed. Then on 7-11-12, the [MEDICATION NAME] was discontinued and [MEDICATION NAME] ordered at bedtime. On 7-12-12, the physician ordered a Broda chair with thigh straps PRN (as needed) for rest periods x 72 hours trial period. (8) On 7-31-12, a bruise was noted to the right wrist. Ice and longer gerisleeves were applied. The physician and family were notified in a timely manner. (9) On 8-14-12, the resident was noted in the sitting position in front of the sofa in the dayroom. No injuries were incurred from this unwitnessed fall. The physician and family were notified in a timely manner. Occupational Therapy screened the resident on 8-15-12 and found her/him with steady ambulation. The OT (Occupational Therapist) provided the resident with a baby doll to see if this helps occupy her (him). (10) On 8-22-12, the resident was noted on the floor in the dayroom. First aid was administered to a bruise and small skin tear on the left elbow. The resident was placed at the nurse's desk for closer supervision. The physician and family were notified in a timely manner. (11) On 8-31-12, the resident was found sitting on the floor in the day room. No injuries were incurred. The physician and family were notified in a timely manner. (12) On 9-3-12, the resident was ambulating in the hallway and fell near her/his room. No injuries were noted. The resident was placed in a reclining gerichair with a tabs alarm per physician's orders [REDACTED]. The physician and family were notified in a timely manner. On 9-3-12, the physician ordered Trazadone decreased to 100 mg at bedtime and [MEDICATION NAME] be given two hours later if still awake as a follow-up to the pharmacist's recommendation. He/she also decreased [MEDICATION NAME] to 1 mg three times daily and discontinued the [MEDICATION NAME]. (13) On 9-5-12, a family member pushed the resident's chair up to the table and caught the resident's hand between the chair arm and table resulting in a skin tear to the right hand. First aid was administered. The physician was notified in a timely manner. On 9-11-12, the physician decreased the resident's [MEDICATION NAME] to 0.5 mg three times daily. (14) On 9-12-12, the resident was noted with a skin tear to the back of her/his leg where the Wanderguard bracelet was rubbing the area. First aid was applied. The physician and family were notified in a timely manner. (15) On 9-19-12, CNA notified nurse of resident's condition, hematoma present to right forehead, side of head, and behind right ear. The physician and family were notified in a timely manner and the resident was sent to the hospital for evaluation. Review of the care plans and Social Services Progress Notes revealed that the family had been involved with each interdisciplinary care plan meeting (5-22-12, 7-3-12, 8-13-12). The care plan included problems related to dementia/behaviors, fragile skin/ tears, and falls with measurable goals and viable approaches. The Care Plan was updated with falls and interventions to prevent falls and/or minimize injury while keeping the resident as mobile as possible. Further review of the interventions for falls revealed that, although the 6-27-12 physician's orders [REDACTED]. Review of Hospice information revealed that the initial referral/coverage date was 12-13-11, prior to nursing home admission. The primary coverage [DIAGNOSES REDACTED]. The most recent care plan included provision of aide services four times per week and nursing services twice weekly. Renew of the biweekly care plans revealed that Hospice had been kept updated on the resident's condition. On 9-19-12, her/his regular Hospice caregiver saw the resident. S/he noted on the Hospice report that the resident was up in the chair, and that s/he assisted with range of motion exercises, took vital signs, provided homemaking activities, assisted with a meal, encouraged fluids, and provided personal care including skin care, shower, shampoo, oral hygiene, linen change, brushed hair, and assisted with dressing. In the visit notes, the Hospice Aide did not identify any concerns with Resident #20 until s/he became combative when I shampooed her/his hair. According to her/his written statement, the Hospice CNA did not notice anything until s/he began to towel dry the resident's hair. Then, I noted a small amount of blood on a piece of hair lying on her/his forehead. I then noticed a bruise on the right portion of her/his forehead, about 1 inch from her/his hairline. At this time, s/he notified the nurse of the resident's condition. There was no mention of bruising prior to entry into the shower, though the report indicated a number of activities had been done with the resident prior to going to the shower. Review of Nurse's Notes, in addition to the above, revealed that the resident was admitted with multiple bruises and a history of wandering. On 5-14-12, after the resident had sustained falls on 5-8-12 and 5-9-12, the resident's sons were noted taking pictures of the resident. On 5-28-12, it was noted that the resident needed monitoring for wandering. Will go in other residents' rooms at times. On 5-29-12 at midnight, s/he was restless with lots of anxieties. Multiple entries were made related to continued pacing and being up all night. Interventions included engaging the resident on a 1: 1 basis and keeping her/him near the nursing station. On 6-26-12, it was noted that the resident follows very few verbal requests. On 6-27-12, an entry noted that a meeting was held with the family to discuss falls, pacing, and interventions. Restraints were also discussed. On 7-3-12, a Care Plan meeting with the family resulted in the resident being moved into a room closer to the nursing station. On 8-10-12, an entry noted that the resident was agitated and slaps staff when try to redirect resident. Again on 8-15-12 and 9-11-12, the resident was combative when attempts were made to redirect her/him. On 9-18-12, the 11-7 shift nurse documented vital signs within normal limits. Resident asleep. Arouses to stimuli. But returns to sleep very easy. No cough or congestion turn and reposition every 2 hours. On 9-19-12 at 8 AM: Hospice CNA called this nurse to shower room. Resident was sitting in shower chair outside of 2nd shower stall, noticed hematoma with bleeding to right side of resident's forehead. Resident alert, responding to verbal stimuli, attempting to stand from shower chair while collecting data to report to MD (medical doctor) & ER (emergency room ), also noted hematoma to right side of head and behind right ear. VS (Vital Signs): BP (Blood Pressure) 112/64, p (ulse) 101, T (emperature) 98.4, R (espirations) 20; MD notified- orders to send to ER for evaluation & treatment. 911 called-report given . Responsible Party made aware . At 8:15 am, the resident was transported continues to be alert & responsive. At 12:45 PM, the Administrator was questioned as to how CNAs were made aware of special needs related to resident care. S/he stated that the facility did not use a kardex type system but that an information sheet was placed on the inside of the closet door. The posting included such things, as transfer assistance needed, ambulation, feeding, bowel & bladder status, and special instructions such as alarms, helmet, etc. In reference to Hospice, s/he stated that the Staff Development Coordinator went over policies and procedures when the staff was first assigned to the resident. During an interview at 11: 50 AM on 5-3-13, Registered Nurse #1, who assessed the resident prior to transport, read and verified her/his written statement which had been part of the facility's investigation. The nurse described the knot on the resident's forehead that s/he had observed as golf ball size. When asked if s/he could tell if the injuries had just happened, the nurse stated, It did not look days old. It was very obvious. S/he stated that if the resident had not had the helmet on, it should have been visible to anyone in the hall. Review of the nurse's written statement revealed that s/he found the resident's helmet in her/his room on the overbed table with no signs of blood on it. During an interview at 1 PM on 5-3-13, CNA #1 stated that at approximately 6:55 AM on 9-19-12, s/he made rounds with the 11-7 CNA. S/he stated they did not disturb the resident because s/he was a fighter. S/he just stepped inside the room and saw the resident sleeping with her (his) helmet on. As s/he was not yet ready to work with the resident, s/he continued with other duties. Between 7 & 7:30 AM, the CNA noticed the resident's call light come on. When s/he answered the light, the Hospice Aide was getting clothes together by the closet. The CNA stated s/he was at the door and the resident was sitting up in bed with her (his) helmet in her (his) hand. The CNA went to get linen for the Hospice Aide and returned to the room. At this point, CNA #1 stated s/he bent down to talk to the resident. S/he was very close to the resident's face and would have noticed any injury. S/he said s/he later saw Hospice walking the resident to the shower with no helmet. The CNA noted that the resident was supposed to have the helmet on at all times. At 1:25 PM on 5-3-13, a telephone interview was conducted with LPN #1, who had been the 7-3 nurse at the time of the incident. S/he verified the written statement given at the time of the facility investigation that s/he was standing at med cart saw resident ambulating in hallway with Hospice CNA walking toward me to shower room, her (his) helmet was off at this time During an interview at 1:35 PM on 5-3-13, CNA #2 stated, In the shower. The resident would sit and get right backup. S/he thought the resident might have fallen in the wet shower. All someone would have to do is turn away for a minute to get the soap or something. The CNA further stated that the resident was supposed to have the helmet on at all times. |
2016-06-01 |