| 32 |
ASBURY PLACE AT MARYVILLE |
445017 |
2648 SEVIERVILLE RD |
MARYVILLE |
TN |
37804 |
2018-08-20 |
657 |
K |
0 |
1 |
Q9H011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to revise 7 residents' (#119, #28, #34, #39, #40, #47, and #80) care plans after falls with effective interventions to prevent further falls of 52 sampled residents, placing residents #119, #28, #34, #39, #40, #47, and #80 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 facility's failure is likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17, and is ongoing. The findings include: Review of the facility policy Care Planning-Interdisciplinary Team dated 1/1/17 revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan .is at the discretion of the Care Planning Committee . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review revealed Resident #119 had 9 falls from 7/1/17 - 7/10/18 with dates of falls 7/1/17, 8/20/17 (resulting in a laceration to the forehead requiring sutures), 10/15/17, 11/10/17 (resulting in a bone [MEDICAL CONDITION] leg), 11/16/17, 11/19/17, 4/13/18 (resulting in a femur fracture), 6/27/18, and 7/10/18. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #119 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was dependent for toileting. Continued review revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Medical record review of the Care Plan dated 12/24/15 and revised 7/10/18 revealed the care plan was not revised with the interventions indicated by falls investigations including to toilet every 2 hours (10/15/17 fall), toilet more frequently and utilize bean bag (11/16/17 fall), and for Velcro noodles to mattress rail (7/10/18 fall). Interview with Nurse Mentor (nurse Unit Manager) #1 on 8/18/18 at 9:25 AM in the Mentor's office, confirmed .All of us are responsible to make sure the intervention is to be implemented (revised) on the care plan .Ultimately the mentor is responsible . Interview with the Director of Nursing (DON) on 8/18/18 at 10:36 AM in the conference room, confirmed the care plan had not been revised to include new interventions for toileting interventions (10/15/17 fall and 11/16/17 fall) and Velcro noodles to the mattress (7/10/18 fall) . Medical record review revealed Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #28's current care plan, not dated revealed, (Resident #28) is at risk for falls d/t (due to): Decreased mobility, LT (left) [MEDICAL CONDITION] s/p (status [REDACTED]. Actual Falls: 5/19/17, 6/17/17, 2/15/18 with FX (fracture) L (left) distal femur (resolve) Interventions: Assist (Resident #28) to wear non-slick footwear that fits. Attempt to engage (Resident #28) in ADL's (Activities of Daily Living) that improve strength, balance and posture. Instruct (Resident #28) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within reach, Instruct (Resident #28) to use call bell or call out of assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of an Incident/Accident Report revealed Resident #28 had a fall on 2/15/18 at 9:45 AM, in the resident's room with injury. Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: Ensure w/c (wheelchair) is within reach while in bed . Medical record review revealed the resident's care plan was not revised to include the intervention to keep the wheelchair within reach while the resident was in bed. Review of an Incident/Accident Report revealed Resident#28 had a fall on 6/7/18 at 2:00 PM in the dining room, CNA (Certified Nurse's Assistant) observed res. (resident) topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @(at) this time . Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: leaning forward in w/c . Medical record review of the resident's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 6/7/18. Interview with Licensed Practical Nurse (LPN) #4 on 8/17/18 at 4:36 PM, in the secure unit, revealed the Household Nurse Mentor for each unit was responsible for updating a resident's care plan after a fall. Interview with Household Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurse's office, revealed the Mentor was responsible for updating Resident #28's care plan with new fall interventions. Continued interview and review of the resident's care plan with the Nurse Mentor confirmed the resident's care plan had not been revised after the resident's fall on 2/15/18 to keep the resident's wheelchair within reach, and confirmed the facility failed to update the resident's care plan after the resident's fall on 6/7/18. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #34 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #34's current care plan, not dated, revealed, (Resident #34) is at risk for falls related to Decreased Mobility, Scoliosis, Narcotic and [MEDICAL CONDITION] Medication Use . Continued review revealed the following interventions: .Assist with toileting as needed. Attempt to engage (Resident #34) in ADL's that improve strength, balance and posture. Fall risk assessment as indicated. Keep call light within reach and remind how to use as needed. Keep room free from clutter, walkways clear. Keep frequently used items within reach. Monitor medications for changes that may effect falls. Footwear will fit properly and have non-skid soles. Instruct (Resident #34 on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .Goals: Resident #34 will have no falls this review period . Review of an Incident/Accident Report revealed Resident #34 had a fall on 2/25/18 at 4:30 AM in the resident's room .Heard someone crying and found pt (patient) on the floor in her room. She states she was going to BR (bathroom) and fell . C/O (complain of) lt (left) hip pain. Skin tear to Lt elbow . Continued review revealed, Additional comments and/or steps taken to prevent recurrence: Call before you fall posted . Medical record review of the resident's care plan revealed Resident #34's care plan was not revised to reflect the resident's fall on 2/25/18 or the new intervention to post the call before you fall sign. Review of an Incident/Accident Report revealed the resident had a fall on 6/16/18 at 9:55 PM in the resident's room .I was told by CNA (Certified Nurse Assistant) that resident was on the floor in her room, went to assess resident, she had skin tear to lt. hand, bump on left side of head and was c/o lt hip pain . Further review revealed, .Additional comments and/or steps taken to prevent recurrence .Call before you fall, posey grip (rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair) . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall the resident had on 6/16/18 or the new intervention to add the posey grip to the wheelchair. Review of an Incident/Accident Report revealed the resident had a fall on 7/14/18 at 7:05 PM in the resident's room .Resident's roommate was calling for help (staff) and I went to the room and resident was on the floor in front of the sink and blood was pooled around her head . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall on 7/14/18 or the intervention to .encourage out of room more . Interview and review of the resident's care plan on 8/18/18 at 12:08 PM with the DON, in the conference room, revealed the Household Nurse Mentors on the units were responsible for ensuring revisions to the care plan were completed after a fall. Continued interview confirmed Resident #34's care plan had not been revised to reflect any of the resident's falls, and did not accurately reflect the fall interventions. Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 required extensive assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 7, indicating severe cognitive impairment. Medical record review of Resident #39's care plan with a goal date of 6/10/18, revealed the resident was .at risk of falls d/t (due to) weakness, Left sided weakness s/p (status [REDACTED]. Review of the facility documentation revealed the resident had a total of 9 falls between 4/3/18 and 8/11/18. Medical record review revealed Resident #39's care plan was updated to reflect 5 dates the resident had falls: 4/3/18, 4/15/18, 6/7/18, 6/27/18 (fall was actually 6/26/18 according to Icident/Accident Report) and 6/30/18. Continued review revealed the only times the resident's care plan was revised to reflect a new intervention after a fall were 6/7/17 - Call before you fall sign; 6/27/18 (for the 6/26/18 fall) - Pool noodles to bed; 6/30/18 - Frequent rounds; and 7/2/18 - Scoop mattress ordered. Interview with Household Nurse Mentor #2 on 8/15/18 at 7:40 AM, on the 400 unit confirmed the resident's care plan was not revised to reflect new or effective interventions to address Resident #39's continued falls. Interview with the DON on 8/16/18 at 9:30 AM, in the conference room confirmed the facility failed to revise the resident's care plan and failed to implement new or effective interventions to address the resident's continued falls. In summary, Resident #39 had 9 falls between 4/3/18-8/11/18. Interventions on the falls investigation were not consistently placed on the care plan. There were 6 falls with no intervention added to the care plan. Medical record review revealed Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #40 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #40's care plan dated 5/23/18, revealed Resident #40 is at risk of falls due to weakness, History of Falls, Dementia and Hypertension. Interventions including wear non-slick footwear that fits; instruct the resident on safety measures to reduce risk of falls; attempt to engage in activities of daily living (ADL's) that improve strength; balance and posture, and keep areas free of obstacles to reduce the risk of falls or injury Medical record review of facility documentation revealed the resident had a total of 4 falls between 6/27/18 and 8/2/18. Medical record review of Resident #40's care plan dated 8/6/18 revealed the care plan was not updated to reflect the resident had falls on the following dates: 6/27/18, 7/16/18, 7/30/18 and 8/2/18. Continued review revealed the resident's care plan was not revised to reflect new or effective interventions to address the resident's continued falls resulting in the resident sustaining a head injury. Observation and interview with LPN Nurse Mentor #2 on 8/17/18 at 10:00 AM, in the resident's room, confirmed the resident was in bed with the head of the bed up, fall mats to both sides of the bed were without alarms, and the call light was out of reach of the resident. Further observation revealed the Nurse Mentor took the Call Before You Fall sign off the closet door and asked the resident to read the sign. Continued observation revealed Resident #40 held the sign in her hand, smiled, and stated nice. The resident was not able to read the Call Before You Fall sign. Further interview confirmed .She doesn't use the call bell, she hollers for us . Continued interview confirmed the Call Before You Fall sign was not an appropriate intervention for Resident #40 and re-education on the use of a call light for a severely cognitively impaired resident was not an appropriate fall prevention intervention. Interview with the DON on 8/20/18 at 11:15 AM, in the conference room confirmed the resident had multiple falls without appropriate interventions put in place. In summary, Resident #40 had 4 falls between 6/27/18 and 8/2/18. Interventions on the falls investigation were not placed on the care plan. There were no new interventions added to the care plan after each fall. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #47 required extensive assistance of I person with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed, .at risk for falls d/t weakness, RT (related to) acetabular fracture (a break in the socket portion of the hip joint) s/p (status/post) fall, vision impairment, [MEDICAL CONDITION], dementia, anxiety, [MEDICAL CONDITION] disorder, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] med use . Continued review of the care plan revealed, .Actual falls 4/9/18, 4/10/18, 4/11/18, 4/14/18, 4/23/18, 4/25/18, 4/26/18, 4/27/18, 5/6/18 .Goals .will maintain current level of mobility with no increase in the incidence of falls/injuries .Interventions .Assist .to wear non-slick footwear that fits .attempt to engage .in ADLs that improve strength, balance, and posture .instruct .on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .keep areas free of obstructions to reduce the risk of falls or injury .keep nurse call light within easy reach .Instruct .to use call bell or call out for assistance .keep personal items within easy reach; bed to be in lowest position with wheels locked .bean bag provided to reduce the risk of falls .self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM revealed Resident #47 .crawled from his room into (another room). Multiple skin tears on bilateral elbows and L (left) knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 4/5/18 or the intervention to post call before you fall sign. Review of an Incident/Accident Report dated 4/9/18 and timed 10:30 PM revealed the resident had a fall in the resident's room without injury .called to resident room. CNA report that resident had been on floor mat by bed on knees . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: call before you fall, increased rounds . Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the new intervention of increased rounds. Review of an Incident/Accident Report dated 4/11/18 and timed 2:45 PM revealed, .sitting in wheelchair in day room with spouse. Leaned forward and slid out of chair. Landed on buttock . Continued review revealed, .Additional comments and/or steps to prevent recurrence: Informed spouse of need for full time sitter . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the recommendation for the family to hire a sitter. Medical record review of a nurse note dated 4/25/18 revealed, .resident was transferred to floor (to another unit) .he has been getting out of his w/c since he arrived to floor, causing his personal alarm to go off, staff has been able to prevent resident from falling or scooting on the floor up to this point, he has wandered in the area between staff bathroom and med room and scooted himself out of his chair and onto the floor .transferred back to his chair after assessment for injury . Medical record review of the resident's care plan revealed the use of a personal emergency alarm for the resident was not included on the resident's care plan. Review of an Incident/Accident Report dated 4/25/18 and timed 11:30 PM revealed, .CNA notified this nurse that resident was lying in floor beside bed . Review of a Fall Investigation Tool dated 4/25/18 revealed, .intervention .fall mats . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the use of fall mats for the resident. Review of an Incident/Accident Report dated 6/13/18 and timed 11:50 AM revealed, .called to room by PT (physical therapy) staff. Pt (patient) was already back in bed but was asleep on mat beside bed when physical therapy found him .he says 'I did not fall or get hurt' . Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: offer rest periods, know whereabouts . Medical record review of Resident #47's care plan revealed the care plan was not revised to reflect the fall on 6/13/18 and was not revised to reflect the interventions of offering rest periods and .know whereabouts . Observation and interview on 8/18/18 at 3:50 PM, in the resident's room, with CNA #17 revealed no call before you fall sign posted. Interview with CNA #17 confirmed fall mats were located on each side of the resident's bed (not on the resident's care plan). Continued interview revealed the CNA had never known the resident to have had any alarms or seatbelts since the time the resident was moved to the secure unit (approximately 2 months ago). Continued observation in the resident's room also revealed no bean bag chair was in the resident's room as documented on the resident's care plan. Interview and review of Resident #47's care plan with the DON on 8/20/18 at 3:45 PM, in the conference room, revealed the Household Nurse Mentor was responsible for ensuring revisions to the resident's care plan after a fall. Continued interview and review of Resident #47's care plan confirmed the resident's care plan was not revised to reflect the fall on 6/13/18 or the interventions of offering rest periods and .know whereabouts . Continued interview confirmed the resident's current plan of care did not accurately reflect the actual interventions which were observed to be in place at this time. Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed Resident #80 required extensive assistance with bed mobility and personal hygiene, and was totally dependent upon staff for dressing, eating and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the quarterly care plan undated revealed Resident #80 was at risk for falls. Further review revealed Resident #80's care plan was not updated with effective interventions after falls on 3/1/18, 4/20/18 and 6/19/18 nor after a fall with serious injury on 7/2/18. Medical record review of the clinical notes dated 7/2/18 revealed .returned from (hospital) .C1(cervical)-C2 Fx (Fracture) and Aspen (Rigid neck brace) collar placed around residents neck, collar is to stay in place for 3 months .laceration to forehead with stitches .will continue to monitor . Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hallway, revealed interventions were to be placed on the care plan and updated by the .care plan manager . Refer to F689 |
2020-09-01 |