| 14293 |
HILLVIEW HEALTH CENTER |
445464 |
1666 HILLVIEW DRIVE |
ELIZABETHTON |
TN |
37643 |
2010-07-29 |
323 |
D |
|
|
R51U11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent accidents and ensure safety devices were in place for one resident (#10) of fifteen sampled residents reviewed. The findings include: Resident #10 was admitted to the facility September 22, 2008, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set ) dated March 7, 2010, revealed the resident had short and long term memory loss, moderately impaired cognitive skills for daily decision making and was independent with ambulation. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory loss, severely impaired cognitive skills for daily decision making, was totally dependent for transfer and locomotion on unit, required a wheelchair for mobility, and had a history of [REDACTED]. Medical record review of Falls Risk Assessments dated September 22, 2008, through June 19, 2010, revealed the resident to be at high risk for falls. Medical record review of the nurse's notes and facility documents dated March 27, 2010, through July 20, 2010, revealed the resident had a history of [REDACTED]. Medical record review of the care plan updated May 22, 2010, following a fall on that date, revealed a planned new approach "...mats placed on left side of bed ..." Medical record review of a facility document dated May 25, 2010, revealed "...resident lying in floor beside of bed..." "Immediate intervention implemented: placed non-skid socks on resident." Further review revealed no documentation the safety mat was in place at the time of the fall. Interview with the Director of Nursing, (DON) July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the mat being in place at the resident's bedside at the time of the fall. Medical record review of the care plan dated June 10, 2010, revealed approaches listed: "...Mats on floor at bedside and bed alarm used for safety...assistance of one or two for transfers and uses a wheelchair for locomotion with assistance of one...Certified Nursing Assistants to assist ...to bed directly after meals...non-skid socks applied." Medical record review of documents provided by the facility dated June 13, 2010, revealed, "resident noted to be laying on floor at doorway to room 30...u-shaped laceration in crown area of head with small abrasion on right side of head...Possible cause of event listed as "...resident up in stocking feet, in hallway walking ..." Immediate intervention implemented..."resident instructed not to ambulate without assistance, to use his wheelchair, and to wear shoes." Further review revealed the facility implemented additional interventions: "...6-13-10 bed alarm; 6-14-10 moved to Rm (room) ... for closer observation ..." Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, revealed the resident had got out of bed and ambulated to the doorway and confirmed there was no documentation the resident was wearing non-skid socks, no documentation the bed alarm or mat was in place at the time of the fall. Medical record of the facility document dated June 18, 2010, at 2:20 a.m., revealed "...resident sitting on floor beside of bed next to window ...1 cm skin tear on left hand ...0.25 cm bruise on right arm, abrasion on lower right side of back..." Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the care planned non-skid socks on the resident, the mat on the floor at bedside, or of the bed alarm in place and functioning at the time of the fall. Observation on July 29, 2010, at 10:00 a.m., in the resident's room, revealed the resident to resting on the bed. The pad was on the floor at the left side of the bed, the pressure pad alarm was still in place, but the non-skid sock was not on the right foot. |
2014-02-01 |