cms_TN: 78
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 78 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 323 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure fall interventions were in place to prevent potential falls, to ensure the correct side rail type was in place for the resident and failed to assess residents for the use of the side rails for .and have the manufacturer's information for the side rails available prior to using the full side rails for 3 of 5 (Resident #25, 54, and 62) sampled residents of the 43 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The assessment was coded to indicate he had long and short-term memory problems, was inattentive and had an altered level of consciousness. According to the assessment he required extensive assistance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff. Review of a BIMS assessment dated [DATE] revealed he had a BIMS score of 0 indicating he was severely cognitively impaired. Review of current physician orders revealed he had an order for [REDACTED]. The order had and an original order date of 11/27/15 and did not specify the type of side rail to be used. Review of the Evaluation for use of Side Rails dated 06/07/17 and signed by Licensed Practical Nurse (LPN) #2 was marked side rails not indicated at this time and the use of the side rail and risk of entrapment related to the use of the side rail was not assessed. Review of the resident's current fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury due to having the [DIAGNOSES REDACTED].osteoporosis . The fall plan of care and the activities of daily living plan of care did not include the use of the side rail. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. The bed was at a regular height (not low). LPN #2 verified Resident #25 was supposed to have the full side rail on the left of the bed raised to assist him with positioning. LPN #2 lowered the full side rail on the right side of the bed. Interview with LPN #2 on 6/11/17 at 2:50 PM, in Resident #25's room, LPN #2 stated, .when both side rails were up they restrained the resident from sitting up on the side of the bed . Interview with LPN #1 on 6/14/17 at 12:10 PM, verified the MDS assessment dated [DATE] was not accurate as it was coded to indicate side rails were not used .and the Evaluation for the use of the Side Rails dated 6/7/17 was not accurate as it was marked side rails not indicated at this time. LPN #2 verified the plan of care did not include the use of the side rail and there was no assessment related to the resident's risk of entrapment and verified the assessment did not include other appropriate alternatives to the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 had severe cognitive deficits, and required extensive assistance for bed mobility. Review of the physician's order sheets dated 5/30/17 documented orders for a bed alarm for fall prevention and bilateral safety mats next to bed. The physician's orders did not include an order for [REDACTED]. The current plan of care for falls dated of 8/16/16 documented the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall related injury by utilizing fall precautions through the next review date of 7/11/17. The interventions included the use of quarter side rails as enabler's and right and left fall mats. The plan of care did not include the use of the physician ordered bed alarm. The most current Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicates the resident is at risk). According to the evaluation the resident was at risk due to behavioral symptoms, being incontinent, using side rails, not able to balance without physical assistance, and the use of antipsychotic medication. Review of the most current Evaluation for Use of Side Rails form dated 4/10/17 assessed the resident as using right and left upper half side rails to assist in turning from side to side and to provide a sense of security. The evaluation did not include an assessment for the least restrictive or other alternatives to the use of the side rails. Review of a Physician's follow-up progress note dated 3/15/17 revealed the physician wrote the resident was restless. The physician's note documented the resident's behaviors were discussed with nursing. The physician wrote fall precautions in place-has a low bed/bed alarm. The progress note did not include the use of the side rails. The Facilities Management Department Work Request dated 5/25/17 documented the bed was to be replaced due to the bed control not working. The invoice documented the bed was replaced on 5/26/17. Interview with LPN #2 revealed, .when the maintenance department replaced the low bed with quarter side rails they replaced it with a regular bed with full side rails . Observation in Resident #54's room on 6/11/17 at 2:34 PM, Resident #54 was observed in bed and the bed was not in the low position and full unpadded side rails were raised. No bed alarm was present on the bed. Observations in Resident #54's room on 6/11/17 at 4:00 PM, Resident #54 was in bed with bilateral unpadded full side rails in place, the bed not in the low position and no bed alarm was in place. LPN #2 verified the observation. After looking at the plan of care, she verified the resident should have quarter side rails in place and not full side rails. Observations in Resident #54's room on 6/11/17 at 4:55 PM, Resident #54 was in a low bed with quarter side rails but there was no bed alarm in place. Observations in Resident #54's room on 6/12/17 at 7:37 AM, 6/12/17 at 2:04 PM, 6/12/17 at 3:22 PM, and 6/13/17 at 7:41 AM revealed the resident in a low bed with quarter upper bilateral side rails, and no bed alarm in place. On 6/13/17 at 7:44 AM, LPN # 2 verified the resident did not have the fall mat on the floor on the right side of the bed. On 6/13/17 at 7:58 AM, LPN #12 was informed of the resident not having the fall mat on the floor on the right side of the bed. After checking the physician's order, she went into the room obtained the fall mat form the corner of the room and placed the mat on the floor on the right side of the bed. On 6/12/17 at 3:22 pm, LPN #4 verified the resident did not have a bed alarm in place and further stated she was not sure if the resident was supposed to have a bed alarm in place . On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. She verified the resident was supposed to have bilateral quarter side rails, a low bed, a bed alarm, and bilateral safety mats on the floor when he was in bed. She also verified the resident had no assessment for the least restrictive device or an alternative to the use of the bed rails. 3. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enablers but did not include the type of side rails (i.e. full, half or quarter side rails). Review of the Evaluation for use of Side Rails dated 5/12/17 revealed the assessment was coded side rails not indicated at this time. The assessment did not include an evaluation of the side rails or of her risk of entrapment and did not include an assessment of appropriate alternate interventions. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated, .the resident was not mentally capable of requesting the use of the side rails and it was the resident's family who requested them . She also verified the Evaluation for use of Side Rails dated 5/12/17 was inaccurate as documented side rails not indicated at this time and bilateral full side rails were in use at the time the assessment/evaluation was completed. She verified the assessment lacked an assessment for risk of entrapment and other appropriate interventions. Interview with the Administrator on 6/13/17 at 8:41 AM, the Administrator and Director of Nursing verified Resident #25 was in bed with bilateral full side rails up on the bed. Certified Nursing Assistant #5 stated the resident always has full side rails up on both sides of the bed. | 2020-09-01 |