cms_TN: 285
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 285 | WESTMORELAND HEALTH AND REHABILITATION CENTER | 445114 | 5837 LYONS VIEW PIKE | KNOXVILLE | TN | 37919 | 2018-07-14 | 835 | J | 1 | 0 | K2OF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, interview, and observation, the Administrator failed to ensure facility policies were implemented, physicians were notified timely of changes in condition, and residents were free from neglect, avoidable accidents, and pain. The Administrator's failure resulted in a resident having an avoidable accident and a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side) Review of the facility's incident report and investigation dated [DATE] at 6:45 AM, revealed Certified Nursing Assistant (CNA) #8 was changing Resident #7's bed linen without assistance of a second staff person, and Resident #7 fell in the floor landing on her knees. Medical record review of the resident's nursing notes and Medication Administration Record [REDACTED]. Further review revealed the physician nor Nurse Practitioner (NP) was notified of the resident having pain, bruising or swelling in her knees and was not assessed at any time after the fall by the physician or NP. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Medical record review of nursing notes, radiology reports, and physician's orders revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM, but there was no documentation the physician or NP was notified of the results. Further review revealed Registered Nurse (RN) arranged an appointment with an orthopedic physician for [DATE] and there was no physician's order for the orthopedic consult. Medical record review of the nursing notes and MAR for [DATE] through [DATE] revealed the resident continued to experience pain, swelling, and bruising in her knees and legs. Further review revealed no documentation the physician or NP was notified of the pain or results of the x-rays, and no documentation the resident was assessed by the physician or NP. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it is quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interviews with CNA #8, RN #2, RN #4, CNA #4 during investigation [DATE] - [DATE] revealed the resident continued to complain of severe pain and staff reported the resident's condition to the DON and Assistant Director of Nursing (ADON), who failed to ensure the physician or NP was notified of the resident's condition and assessed the resident. Staff interviews revealed the physician and NP were not notified of the resident's pain or results of the x-rays indicating the resident had bilateral fractures, and the physician and NP did not assess the resident. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about Resident #7's accident. Continued interview with the DON revealed he did remember several days after Resident #7's fall when he was made aware the resident was having a lot of pain. Observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed she had not seen the sign hanging at the nursing station to call the nurse supervisor before calling the physician or NP. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed when asked when did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed during observation of nursing notes for [DATE] and [DATE] the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything . When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview with the Administrator confirmed, when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays, the Administrator shook her head back and forth and said .no . Further interview with the Administrator revealed QA meetings were conducted on [DATE] and [DATE] at which time only number of incidents and location of the incidents were presented. Continued interview revealed no fractures were reported during these meetings. | 2020-09-01 |