cms_SD: 45
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 45 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 689 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > [NAME] Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (17) who had verbal, physical, and sexually abusive behaviors had been adequately supervised to protect the other residents from harm. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment. *For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center. *For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed necessary (Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting process), including feedback from the Medical Director. *For staff education: -Immediate education will be completed with all staff prior to their next shift, which will include the review of the following policies: Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting Process. We will focus on identifying signs and symptoms of abuse, how to report, when to report and who to report to in order to address the potential for a similar situation in the future. Staff will be knowledgeable about protecting themselves and other residents in accordance with our policies. Education completion will be reported to the Administrator. *For Medical Director education: -The review of the admission process and following policies will occur with the Medical Director upon his return the week of 3/19: Abuse and Neglect; Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident abuse; Preventing Resident Abuse, Resident Rights; Resident Incidence/Variance Reporting process. On 03/27/18 at 11:45 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observations, interviews, and record reviews during the survey on 3/12/18 through 3/15/18 and 3/27/18 through 3/28/18 related to resident 17 and his verbal, physical, and sexually abusive behaviors revealed: *He was not appropriately supervised and monitored to protect the other residents and staff members health and safety. Refer to S550, findings 1, 2, and 3. Refer to S600, findings 1, 2, 3, 4, and 5. Review of the provider's 1992 Briggs Healthcare pamphlet in the admission folder regarding resident rights revealed: *As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights. *Exercise of rights: You have the right and freedom to exercise your rights as a resident of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion, or reprisal. *Resident Behavior and Facility Practices: -Abuse You have the right to be free from verbal, sexual, physical or mental abuse. -Staff treatment: --The facility must implement procedures that protect you from abuse, neglect or mistreatment. --In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. --All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. *Quality of life The facility must care for you in a manner and environment that enhances or promotes your quality of life. Review of the provider's 6/13/16 Safety and Supervision of Residents policy revealed: *Policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. *Resident supervision is a core component of the systems approach to safety. Review of the provider's 6/27/16 Abuse Investigations policy revealed: Policy statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the provider's 5/20/03 Resident-to-Resident Abuse policy revealed: *All forms of abuse, including resident-to-resident abuse, must be reported immediately to the nursing supervisor, the director of nursing services, and the administrator. *Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents must be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. *Should a resident be observed/accused of abusing another resident, our facility will implement any or all of the following actions: -Document in the resident's clinical record all interventions and their effectiveness. -Consult psychiatric services for assistance in assessing the resident and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. -Complete an incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record. -Transfer the resident if deemed by the interdisciplinary care planning team and medical director as being a danger to him/herself or to others for psychiatric evaluation. -Report incidents, findings, and corrective measures to appropriate agencies as outline in our facility's abuse reporting policy. B. Based on observation, interview, record review, and policy review, the provider failed to ensure two of four sampled residents (5 and 41) who had multiple falls had possible causes of their falls identified and appropriate interventions initiated and implemented to possibly prevent further falls: *From her admission on 8/1/17 through 3/15/18 resident 41 had seventeen falls. -Seven of those falls had injury. *From (MONTH) (YEAR) through 3/27/18 resident 5 had seven falls. -Three of those falls had injury. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. *She was dependent on the staff to: -Anticipate her care needs. -Initiate and implement interventions to ensure her safety was maintained from injury and harm. Review of resident 41's Regional Falls Risk Assessments from her admission through 3/15/18 revealed: *According to the provider's revised 6/13/16 Fall Prevention policy a score of ten or higher indicated a risk for falls. *On 8/1/17, 8/7/17, 2/19/18 her score was twenty-six points. *On 11/5/17 her score was twenty-eight points. *She was at risk for falls due to her: -History of falls. -Impaired cognition. -Impaired vision. -Need for assistance with toileting. -Impaired mobility and balance. -Advanced age. -Health conditions. -Medications. Observation on 03/12/18 at 04:38 p.m. of resident 41's room revealed: *She had a low bed with an air mattress on it. *There were repositioning bars on both sides of the bed. *There was a fall mat folded up and placed at the foot end of the bed. *She had a doll and teddy bear laying on top of the bed. *There was a four-wheeled walker in her room. Observations throughout the day on 3/13/18 from 7:30 a.m. through 6:30 p.m. of resident 41 revealed: *She was cognitively impaired and appeared to become more anxious later in the day. *She required assist of one to two staff with transfers and personal care. *She used a wheelchair for mobility. -She could propel the wheelchair herself or had staff assist her. *Her wheelchair had an anti-roll back device on the back. Observation on 03/13/18 at 08:19 a.m. of resident 41 in her room revealed: *She was in her bed sleeping. *The bed was low to the floor with a floor mat beside it. *She had repositioning bars on both sides of the head of the bed. *She had a mobility alarm on the bed, and the lights were low in the room. Observation and interview on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during resident 41's personal care revealed: *The resident had been out at activities in her wheelchair and was wheeled into the bathroom by the CN[NAME] -She was wearing slippers on her feet and compression stockings to both lower legs. *She required staff assistance with most of her activities of daily living (ADL) due to her impaired cognition and history of falls. *She fell frequently and usually got hurt when she had fallen. -Her injuries included skin tears, bruises, hitting her head, a shoulder dislocation, and recently a broken arm. *She had recently come back from the hospital after a fall where she had broken her arm. -After she had returned from the hospital she spent a lot more time in bed than she had done prior to her injury. *She had alarms to alert staff when she was trying to transfer herself. Observation and interview on 03/13/18 at 11:17 a.m. with registered nurse (RN) [NAME] and licensed practical nurse (LPN) D in the resident's room revealed:*She was supposed to wear her foam boots to both feet at all times for pressure relief related to pressure injuries on both of her heels. -An air mattress was also put on her low bed after those areas had been noted. *She required staff assistance with her ADLs due to her impaired cognition, immobility, and history of falls. Review of resident 41's interdisciplinary progress notes and incident reports including the investigations from her admission on 8/1/17 through 9/30/17 revealed: *At the time of her admission on 8/1/17: .Resident was living at an assisted living home and experienced several falls .Resident is a fall risk, so to have alarms on at all times. Can transfer with 1 assist and gait belt. Unsteady on her feet . *On 8/3/17 she had an unwitnessed fall between the office and the dining room and hit her head causing a cut to her left eyebrow. -The 8/3/17 progress note included: --Chair alarm was listed for alarms used and functioning properly. --Yes was listed for the care plan reviewed and updated. --Go to assisted dining room per family request was the suggested intervention. -An 8/7/17 note on the incident report included Fall meeting: Resident had a fall on 8/3/17 in dining room .She was carrying her dishes .Interventions to prevent future falls include pressure alarm to bed and w/c and moving resident to hall 300 dining room where she can be monitored closely. --According to the 8/1/17 note above the pressure alarm had already been in place prior to that fall. -An 8/14/17 progress note that was also on the incident report stated Fall meeting: Discussed resident's fall on 8/3/17. Resident continues to eat her meals in the 300 Hall dining room and reports being comfortable and happy there. Staff say that the resident turns off her pressure alarm and still gets up un-assisted to ambulate. Resident is pleasant, but very difficult to re-direct due to poor memory and does have reported episodes of 'sun-downing.' She cont. on therapy and cooperates well with them. Resident can ambulate w/ (with) assist and FWW (front-wheeled walker). --That note had not mentioned a change in interventions. *As of 8/9/17 there was minimal documentation related to transferring herself, behaviors, or delusions. *On 8/11/17 a progress note stated .needs to focus on walking, staff can now walk with her to meals, etc with hand hold assist, needs frequent frequent reminders to ask for assistance. Therapist is working on education for how safety alarm works and her responses to it . *On 8/12/17 a progress note stated .able to walk with standby assist for over 200 feet, working with resident to recognize sound of safety alarm and how to react . -It was unclear why the resident needed to know how to react to the alarms. --Unsure if the alarm would have been an appropriate intervention, because the resident was able to shut the alarm off. *On 8/15/17 she had an unwitnessed fall in the hallway near the vending machines. -The progress note for the fall included: --No was documented for her alarm use and function. --Yes was listed for care plan reviewed and updated. --Resident to have cane or 4 wheelwalker at all time was listed for a suggested intervention. ---That was not a new intervention. -Several days later there were notes on the incident report from fall meetings that included: --On 8/21/17 PT to eval if needs walker. Staff informed that she must have someone walk with her. and Fall Meeting: Discussed resident's falls on 8/3 and 8/15/17. Resident now has rolling wheeled walker. She still requires staff to walk with her. Resident turns her pressure alarms off. Continues to work with therapy. --On 8/28/17 .discussed resident's fall on 8/3/17 and 8/15/17. Resident continues to work with therapy. They have given her a 4WW (four-wheeled walker). Resident seems to enjoy using this b/c (because) she can set her 'baby' (a stuffed toy mouse named [NAME]) on the seat and push him around. Does have pressure alarm on bed and chair, she is not supposed to be up ad lib per therapy. However, resident turns her alarms off and frequently gets up w/o (without) assist. Very poor memory. --On 9/6/17 .Resident continues to get up un-assisted and walk w/o her FWW. Staff has to frequently go get her walker for her. Resident has very poor memory and requires on going supervision. -There was no mention of any new interventions other than the stuffed toy mouse. *From 8/15/17 through 9/12/17 progress notes indicated she continued to work with therapy, would transfer herself at times, and would forget her walker at times. *On 9/12/17 she had an unwitnessed fall in her room. -There was no mention of any new interventions in the incident report. -The progress note included: -No alarms for alarm use and functioning. -No response for the care plan being reviewed or updated. -Res. (resident) already with frequent checks and has continuous reminding to call for help was the suggested intervention. --That was not a new intervention. *It was unclear when the alarms were discontinued through review of the progress notes from 8/28/17 through 9/12/17. *On 9/25/17 she had an unwitnessed fall in her room, hit her head causing a laceration to her right forehead, and was sent by ambulance to the emergency room for evaluation. -Notes on the incident report on 9/27/17, 10/2/17, and 10/4/17 included: -- .CNA says that resident appears to become more agitated and impulsive towards the evenings. Note left for Dr. (name). Nurse encouraged to use her PRN [MEDICATION NAME] if other interventions are not successful. --The other interventions were not mentioned. -The progress note for the fall included: --N/A was documented related to her alarm use and function. --No was listed for care plan reviewed and updated. --None was listed for suggested interventions. *On 9/29/17 she had a witnessed fall by the door of the dining room while walking independently with her walker. -The incident report included a fall meeting note on 10/4/17 that stated .went over resident's falls. Risks, possible triggers, timing, resident's thoughts, etc. were discussed. The team feels that the resident's delusions are leading to her falls i.e. hearing voices, worried that she needs to go to work or that her family is looking for her. Staff have reported her behaviors escalate dramatically in the evenings. They have tried multiple interventions over several weeks including, but not limited to activities, food, drink, exercise, calling family, etc. Resident becomes inconsolable and very agitated. Dr. (name) placed resident on [MEDICATION NAME]. The team feels that this is in her best interest as her delusions cause her emotional distress and self injurious behavior. --That was the first note mentioning delusions or what interventions they had tried for her behaviors. -Progress note for the fall included: --N/A listed for alarm use and function. --No response for the review and updating of the care plan. --Continue to redirect her on the proper way to use walker was the suggested intervention. ---That was not a new intervention. Continued review of resident 41's interdisciplinary progress notes and incident reports including the investigations from 10/1/17 through 11/30/17 revealed: *On 10/6/17 she had an unwitnessed fall in her room and pulled a shelf down. -There was no mention of a new intervention in the incident report. -The progress note included: --Resident has no alarms, is ambulatory was listed for her alarm use and function. --No response was listed for reviewing and updating the care plan. --Remove resident's personal shelf from room & locate a more stable shelf for her items. was listed for suggested intervention. *On 10/10/17 she had a witnessed fall when attempting to walk without her walker. -The progress notes included: --N/A for the alarms. --No response for reviewing and updating the care plan. --Continue to try and redirect resident was the suggested intervention. -There were no new interventions implemented. *On 10/13/17 she had a near fall in the commons areas for staff outside of the dining room. -Continue to monitor her and attempt to redirect her to use her walker was the suggested intervention. -There were no new interventions implemented. *On 10/24/17 she had an unwitnessed fall in the dining room and dislocated her right shoulder/arm. She was sent by ambulance to the emergency room . -There was no intervention implemented promptly after the fall. -Notes on the incident report included: --Several days later on 10/30/17: Resident prior to fall was in the dining room per staff with a pink bucket (basin). This is not per interview with staff a Witnessed fall. Staff did administer PRN medications when resident became agitated and not redirectable in the most recent past. --Almost two months later on 1/17/18 Fall team met and discussed falls on 12/13/17, 12/17, 1/02/18, and 1/7/18. Resident is on Restorative program for ambulation and is working with therapy on improving toileting with verbal cues, hygiene and self feeding. Is on Q (every) 2 hour toileting, Q 2 hour resident checks. -The progress notes included: --N/A for reviewing and updating the care plan. --Unsure for a suggested intervention. *On 10/28/17 she was sent to the hospital for an upper respiratory infection and was admitted . -She returned to the facility on [DATE]. *On 11/7/17 she had a witnessed fall in the hallway near the dining room where she hit her head and left elbow. -The incident report had not mentioned any new interventions. -The progress notes stated: --Continue to monitor closely, reinforce requesting assistance for a suggested intervention. --No response was listed for reviewing and updating the care plan. *On 11/9/17 she had an unwitnessed fall in the hallway and received a skin tear. -The progress notes included: --Reviewed for care plan reviewed and updated. --Frequent reminders to not try to stand up by herself, constant monitoring as she is impulsive and has dementia for the suggested intervention. -There was no incident report or investigation for that fall. -There were no new interventions implemented. *On 11/13/17 a progress note stated SS, DON and Administrator met with (name) POA of (resident) to discuss increase of behaviors and need of 1:1 (one-to-one) care. Discussed placement in other facilities in Rapid City that have locked units that could be appropriate for (resident). (POA) was open to this possibility if behaviors continue to increase. Will monitor situation, Nursing will give (POA) a weekly call to update on behaviors. -No further notes were found about her being transferred to another facility. *On 11/30/17 a progress note stated Resident was found laying on top of the wood over the bathtub in her bathroom . -There was no incident report or investigation for that fall. -There were no new interventions implemented. Continued review of resident 41's interdisciplinary progress notes and incident reports including the investigations from 11/30/17 through 3/12/18 revealed: *On 12/13/17 she had a witnessed fall in the lobby and bumped her head. -A 1/17/18 note on the incident report over a month later, was the same note as the 10/24/17 fall. -Progress notes included frequent reminders, supervision by staff as the suggested intervention. -There were no new interventions implemented at the time of the fall. *On 12/28/17 she had an unwitnessed fall in her room. - resident laying on ground, next to bed, with gown off and brief pulled down, bed wet. CNA had last been in room [ROOM NUMBER] minutes prior, doing safety check, and at that time resident was asleep. Resident bed in low position, floor mat next to bed (under resident). -There was no mention of when she had last been assisted to the bathroom. -A 1/17/18 note on the incident report several weeks later was the same as the 10/24/17 fall. -The progress note included: --Gripper socks on feet when in bed as a suggested intervention. --Reviewed listed for the reviewing and updating of her care plan. *On 1/3/18 she had a witnessed fall sliding from her low bed onto her fall mat. -The 1/17/18 note on the incident several days later was the same as the 10/24/17 fall. -There were no new interventions implemented at the time of the fall. *On 1/7/18 she had an unwitnessed fall in her bathroom. -The description was Resident states 'I fell and hit my back here' pointing to the bathtub. Resident was sitting on toilet, pull up wet. -Ten days later on 1/17/18 the note on the incident report was the same as the 10/24/17 fall. -There was no response listed for a suggested intervention in her progress notes. -No was listed for the care plan being reviewed and revised. -There was no new intervention implemented. *On 1/31/18 she had an unwitnessed fall in the hall outside her room with injuries. - .resident laying on her left side with blood coming from her left eyebrow and mouth. ROM completed to all but resident's left arm secondary to resident yelling out in pain saying, 'don't touch it, it's broke.' Staff assist x 3 with gait belt to get resident to stand and place in a W/C . -She was sent to the emergency room by staff per facility van and returned later that day. -A 3/1/18 note on incident report over a month later stated Pressure alarm placed with family consent to alert staff of attempt to transfer without assist . -The progress notes from her return on 1/31/18 and through the night had not mentioned what injury had occurred. -A 2/1/18 progress note stated Resident seen and examined for an acute visit due to fall last evening with fracture to left elbow. Dr. (name) applied a posterior splint to the left arm . -There was no mention of new interventions implemented. -Review of the final Required Healthcare Facility Event Reporting form for the 1/31/18 event indicated: --Investigation is ongoing per DON. Resident returned from hospital on [DATE] @ 16:10 with dx (diagnosis) of fx (fracture) to L elbow .Staff per investigation, state she was sleeping in her bed only five minutes prior to her being found on floor .Facility and staff have tried every available option for decreasing her fall risk for example anti roll back on w/c, providing activity/diversion with any increased agitation that was not easily redirected. Primary provider and family discussion with nursing on 2/2 (2/2/18) and decision to initiate pressure alarm to alert staff of resident attempts to self transfer to decrease her risk of falls . -The action taken was other: Discussion with family and Physician on safety concerns. *For the above events there was no evidence to support a thorough investigation had occurred to support: -Staff had been interviewed to give details related to each event. -A root cause of the multiple falls had been or could have been determined. *For most of the above falls appropriate interventions had not been: -Implemented or documented timely. -Related to the possible cause of the fall to potentially prevent future falls. -Realistic due to her level of cognitive impairment. Review of resident 41's 3/14/18 care plan related to falls revealed: *That care plan was requested to be printed with all revisions and edits to show the history. *There was a focus aware of: -I wander and I am unaware of safety needs/my physical limitations resulting in falls. I also have a history of frequent falls, where I injure myself. 10/24/17 - fall with RUE (right upper extremity) dislocation. 1/31/18 - fall in 300 hall attempting to walk unassisted w/ (with) laceration to forehead and major injury to my left elbow. *Goals were: -I will not walk around without my assistive devices and your assist, to eliminate me having a fall. -I will incur no falls or injury through next review date. *Interventions were: -Assist me to toilet every 2 hours. --That was initiated on 1/19/18 and revised on 2/1/18. -Determine if physical needs may be making me restless. Am I hungry? Am I thirsty? Do I need to use the toilet? Am I having pain? --That was initiated on 11/14/17. -Do a fall risk periodically. No bed canes per therapy recommendations. Remind me to have a 'walking partner' as that is the phrase therapy uses. W/c (wheelchair) removed from my room so I do not push it and fall. --That was initiated on 8/16/17 and revised on 9/28/18. --That had not matched her current status of using a wheelchair, having repositioning bars on bed, and not walking the way she used to. -Ensure that I am wearing the splint on my left arm as prescribed. I do try to take it off frequently, wrapping it gently with ace wrap does help. Assess my pain frequently and offer PRN pain medication to keep me calm and comfortable. I am refusing to wear my splint. --Resident had no splint in place during the time of survey. It was unclear when it was discontinued by record review. -Ensure that my bed is in the low position with landing strip (fall mat) when I am napping/sleeping. --That was initiated 2/21/18 after her frequent falls and major injuries. --This was not followed during an observation on 3/28/18. -I am very unsteady, I do have to use my w/c more frequently as I cannot stand/walk w/o (without) my legs giving away. --That was initiated on 11/14/17. -I have anti-roll back bars on my w/c, as I do not understand my limitations and frequently attempt to stand/transfer w/o assistance from my w/c w/o locking the brakes. --That was initiated on 1/25/18 and after most of her falls had occurred. -If you notice that I am up walking unassisted, do not leave me alone, send another staff member to obtain my w/c. --That was initiated on 8/15/17 and revised on 2/19/18. -Keep my bed in low position with landing strip when I am napping/sleeping. --That was a duplicate entry with an initiated date of 2/19/18. -My family and leadership/nursing team here at the facility has decided that I would benefit from a personal pressure alarm. It is necessary for my safety/well being to prevent further falls. My personal alarm will enable me to obtain assistance when I need to get up, as I cannot remember to call for help due to my dementia and do not understand my physical limitation. This alarm does not have any restraining effects on me. --That was initiated on 2/2/18. --There was no mention of her having alarms on admission or when they had been discontinued prior to this. -Orient me to immediate surroundings. -Point out simple landmarks within the facility to me. -Provide me with emotional support for my feelings paired with calm factual information. (inquire where I am going, who I am looking for, why am I sad, anxious, etc.) --The above three interventions were initiated on 10/25/17. -Provide consistency in routine including physical exercise. Include me when possible with tasks, as I love to stay busy and perform household duties. --That was initiated on 10/25/17 and revised on 11/14/17. *It was not clear that interventions were initiated promptly related to her above fall dates. -The interventions frequently had not matched what the nurses stated they would implement in their progress notes or the fall team notes. Phone interview on 03/14/18 at 08:15 a.m. with resident 41's physician who was also the medical director revealed: *The resident had several falls and injuries related to her falls since she was admitted to the facility in (MONTH) (YEAR). *Several of her falls resulted in minor or major injuries including: -Hitting her head. -Bruises. -Skin tears. -Lacerations requiring steri-strips or stitches. -A shoulder dislocation. -A recent arm fracture. *He stated she had poor safety awareness. *Her cognitive impairment caused her to attempt to do things on her own that she should not have done. *He had assisted with changing her antipsychotic medication in hopes to lessen her anxiety and behaviors. *She had a history of [REDACTED]. *He agreed there should have been interventions implemented in an attempt to prevent potential falls and injuries. Observation and interview on 03/14/18 at 01:21 p.m. with LPN A and RN G in resident 41's room revealed: *They indicated the resident had a history of [REDACTED]. -She had gotten injured during some of those falls. *LPN A was a traveling nurse and had worked in the facility for about one month. *RN G had been working in the facility for about a year. *They stated when a resident fell or an incident occurred the nurse should have: -Assessed the resident. -Completed an incident report form. -Documented the incident in the progress notes. -Notified the resident's physician and representative. *Incident reports should have been filled out completely and accurately.<BR/ | 2020-09-01 |