cms_UT: 47
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 47 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 726 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined for 11 of 43 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that licensed nurses have the specific competencies and skill set necessary to care for residents' needs as identified through resident assessments, and described in the plan of care. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, one resident was transferred via a sliding board resulting in a tibial/fibula fracture without the CNA (Certified Nursing Assistant) staff being trained for sliding board transfers, one resident who twisted her ankle and sustained a tibial/fibula fracture was not reported to licensed nursing staff and one resident's change in condition did not get reported to oncoming nursing staff. Additionally, multiple residents medications were either not administered or administered late due to facility staff having to help and train agency staff and residents complained about the issues in resident council meetings. Resident identifiers: 1, 2, 4, 18, 22, 30, 37, 39, 60, 62 and 170. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On [DATE] resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] ,[DATE] mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. [DATE] at 17:56 (5:56 PM), (Recorded as Late Entry on [DATE] at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. [DATE] at 5:50 AM, No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. [DATE] at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on [DATE], no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) ,[DATE] and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. [DATE] at 5:38 AM, C/O (complains of) pain at Rt (right) leg r/t recent fall. Reports about a ,[DATE] because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. [DATE] at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) ,[DATE] and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. An X-Ray report dated [DATE] at 19:27 (7:27 PM) revealed that Bones: Two views were obtained with limited positioning. There is a nearly [MEDICATION NAME] oriented [MEDICAL CONDITION] right tibial metaphysis without any obvious displacement on this AP (anterior-posterior) radiograph. There is also a [MEDICATION NAME] oriented adjacent acute [MEDICAL CONDITION] right fibula but this appears to be associated with an area of old healed fracture as well. There is an old healed [MEDICAL CONDITION] fibular diaphysis .Impression: Acute nondisplaced fractures of the proximal right tibia and fibula although radiographic evaluation is limited . A New Employee Orientation Checklist dated [DATE] for CNA 1 revealed that CNA 1 had been oriented regarding using gait belts for transferring residents safely and the proper way to use mechanical lifts such as a hoyer lift and sit to stand lift. On [DATE], a written statement by CNA 1 was provided by the facility DON. The written statement revealed, Nurse needed (Resident 37) into bed, I was notified she was a 1 person transfer on board. We fixed her shirt for a transfer into bed, she wanted to rest. I fixed her wheelchair to (sic) close to her bed and place (sic) transfer board under her leg and on her bed. Transferred (sic) with barrer (sic) weight 100 %. She tried to help me tranfer (sic) her but got to (sic) weak, she was already on the board between her wheelchair and bed, we tried (sic) to transfer again from same position but slid forward onto my weight and slid off board. Called for help while she was barring her weight on me and no one came. No one came to help, after the fall, she slowly slid on to floor. The Inservice Training/Seminar Report regarding Slide Board Transfer Review that accompanied CNA 1's written statement was dated [DATE]. On [DATE] at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she heard a loud thud the day of resident 37's fall and that CNA 1 started yelling. LPN 1 stated that she went right into the room and assessed resident 37 for injuries. LPN 1 stated that the sliding board had not been placed correctly onto the bed and subsequently had become loose from the bed. LPN 1 stated that resident 37 was not on the bed far enough and started to fall and that CNA 1 lowered her to the floor. LPN 1 stated that her assessment for injuries consisted of placing her hand on resident 37's hip and then bending her right leg up and down at the knee, to see if she could feel any popping out of the hip. LPN 1 stated that she was able to know if there was a problem with her hip if there was popping out. LPN 1 stated that resident 37 was picked up off of the floor to a standing position and assisted back to bed. LPN 1 stated that the CNAs were aware of the transfer needs by resident 37 because they were in a binder at the nursing station. (NOTE: The transfer needs available in the binder were the current needs for resident 37.) LPN 1 stated that the previous paperwork for resident 37's needs had been shredded. On [DATE] at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that the slide board transfer training had not been provided to the CNA staff and that the CNA staff should never have been attempting to transfer resident 37 with the slide board. The facility MDS Coordinator stated that the slide board transfer training had only been provided to the RNA (Restorative Nursing Assistant) staff. The facility MDS Coordinator confirmed that the staff member that had attempted to transfer resident 37 just prior to the fall on [DATE] was a CNA, had never been trained for the sliding board transfer and that she should never have attempted the transfer with resident 37. In addition to resident 37's fall, resident 37 had multiple medications that had been administered late and included the following: According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including [MEDICATION NAME]/[MEDICATION NAME] TID, [MEDICATION NAME] 20 mg at bedtime, [MEDICATION NAME] 3 mg QD, [MEDICATION NAME] 70 mg weekly, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 100 mg TID, [MEDICATION NAME] 2.5 mg QD, [MEDICATION NAME] 20 mg QD, Potassium Chloride 20 mEq BID, [MEDICATION NAME] 40 mg QD, Sprionolactone 25 mg QD, [MEDICATION NAME] 50 mcg QD and [MEDICATION NAME] 200 mg at bedtime. 2. Resident 170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 170's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] New order by MD (Medical Doctor) for the patient: DC [MEDICATION NAME] Inhaler; amt (amount): 2 inhalations; Special Instructions: Dx (diagnoses) [MEDICAL CONDITIONS] Four Times A Day New order: Re-start on [DATE] [MEDICATION NAME] inhaler; amt: 1 inhalations; Four Times A Day Increase monitoring for any respiratory issues. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem. b. [DATE] at 21:30 (9:30 PM), (Recorded as Late Entry on [DATE] at 23:59 (11:14 PM), CNA (Certified Nursing Assistant) came to tell LN (Licensed Nurse) to come check on pt (patient) out of concern. LN went to observe pt. Called pt name and gently shook her shoulder, pt easily roused and responded. Ask how she was feeling and if she was in any pain, stated that she was just tired. Denies pain/discomfort at this time. Pt in no apparent distress. Pt was laying flat, LN raised HOB (head of bed) to semi fowlers. VS (vital signs) checked (Temperature) 98.2, (Pulse) 112, (Respirations) 14, (Blood Pressure) ,[DATE], (Oxygen Saturations) 92% 5L (liters) via NC (nasal cannula). Blood sugar 350. Lung sounds CTA (clear to auscultation) bilaterally. Respirations even and unlabored. Encouraged fluids. Pt checked and changed, barrier cream applied with brief change. Will notify MD. Nursing will continue to monitor. (NOTE: The nursing progress note did not explain what the concern was with resident 170 Additionally, the note was added to the medical record as a late entry after resident 170 had passed away.) c. [DATE] at 00:01 (12:01 AM), Went to check on pt, pt sleeping and easily roused. Responsive and able to respond appropriately to questions. Pt in no apparent distress and denies pain and/or SOB (shortness of breath). Respirations even and unlabored at 14, [MEDICAL CONDITION] (continuous positive air pressure) in place per orders while pt asleep. Nursing will continue to monitor. d. [DATE] at 3:02 AM, Checked on pt, still sleeping and easily roused. [MEDICAL CONDITION] in place and functioning. Woke her up and had her drink some water, responded and drank without any coughing or choking noted. CNA doing regular rounding and brief checks Q (every) 2 hours alternating with LN Q 2 hrs (hours). e. [DATE] at 5:00 AM, Pt check shows pt still sleeping in no apparent distress and easily woken. Cap (capillary) refill f. [DATE] at 5:30 AM, CNA was in room checking pt brief, LN joined to observe pt before the end of shift. Pt respirations even and unlabored. Pt in no apparent distress, skin pink warm and dry. [MEDICAL CONDITION] in place, pt responded to name and gentle shoulder shake. Denies pain, discomfort, or SOB. HOB elevated and RR 14. Encouraged pt to drink fluids throughout the day. Will report to oncoming nurse to monitor pt and encourage fluids throughout the day. g. [DATE] at 8:10 AM, Patient was find (sic) with respiratory distress, unresponsive with minimal arouse (sic), vitals was taking (sic) manually with no reading, patient with pulse 60 per min, respiration 24, laborated (sic) with O2 (oxygen) reading (saturations) 66 5 (66% on 5 liters of oxygen) in [MEDICAL CONDITION], interventions, change to face mask with 6 L oxygen, pull the head back to facilitated (sic) breading (sic) new O2 (saturation) 88%. Blood sugar check, blood sugar: 366 mg (milligrams)/dl (deciliter). Patient was able to open her eyes and was asked if she wanna (sic) go to ER (emergency room ), she state (sic) 'yes', 911 was called and MD notified. h. [DATE] at 11:09 AM, Nurse contact (sic) (Name of Hospital) to follow up condition for the patient. LN was informed patient being admitted to ICU (Intensive Care Unit), it was no (sic) provided diagnostic or reason why patient was admitted to the hospital. They state it is HIPPA (sic) (Health Information Portability and Accountability Act - HIPAA) code. The vital sign report for resident 170 revealed that resident 170's vital signs were monitored and recorded as the following: a. [DATE] at 8:34 AM, Blood Pressure (BP) - ,[DATE], Pulse (P) - 78, Respirations (R) - 16, Temperature (T) - 97.8. O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) b. [DATE] at 9:57 AM, BP - ,[DATE], P - 83, R - 16, T - not taken, O2 Saturation - 90% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) c. [DATE] at 17:25 (5:25 PM), BP - ,[DATE], P - 68, R - 16, T - 97.9, O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air. Additionally, no documentation could be located in the medical record that resident 170's physician had been notified of the decrease in resident 170's BP and P, nor was there continued monitoring of the BP and P after they had decreased.) d. [DATE] at 9:03 AM, BP - not taken, P - not taken, R - 20, T - 97.8, O2 Saturation - 94% physician's orders [REDACTED]. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem had not been included in the order. No documentation could be located in the medical record to show that the nurse called resident 170's physician about the change in condition nor what the change in condition was. On [DATE] at 1:53 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that he was on duty when resident 170 had gone into [MEDICAL CONDITION] and that he was in the room and yelling for help. RN 4 stated that the facility PDON had responded and came into the room. RN 4 stated that he had told the PDON to call 911 and she did. RN 4 did not recall that anyone else was in the room nor that the crash cart had been requested. RN 4 stated that he had been told in report from the night shift nurse that resident 170 was sleepy. On [DATE] at 4:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that she had been called overhead by the facility Past Director of Nursing (PDON). The facility PDON the morning of [DATE] and was told by the PDON to get the crash cart because resident 170 was in [MEDICAL CONDITION]. The facility DON stated that they did not do CPR (Cardiopulmonary Resuscitation) because resident 170 was a DNR. The facility DON stated that she did not document her involvement in the incident because resident 170 went to the hospital. The facility DON stated that she did not know why there were not more vital sign documentation in the medical record after resident 170 had a change of condition, nor why resident 170's physician had not been notified by the facility nursing staff. The facility DON stated that she felt as though it was a documentation error. The facility DON further stated I understand and see why there is a concern with this resident because of the lack of interventions. The facility DON acknowledged that there were no interventions of calling resident 170's physician, monitoring for the change in condition and no vital sign monitoring. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 4's medical record was reviewed. physician's orders [REDACTED]. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 4 had multiple medications administered late including [MEDICATION NAME] 325 mg 2 tablets TID, [MEDICATION NAME] 10 mg QD, Aspirin 81 mg QD, [MEDICATION NAME] 5 mg at bedtime, [MEDICATION NAME] 100 mg BID, [MEDICATION NAME] 40 mg at bedtime, [MEDICATION NAME] 10 mg QD, [MEDICATION NAME] 10 mg QHS, [MEDICATION NAME] 0.5 mg BID and [MEDICATION NAME] 5 mg every six hours. 4. On [DATE] at 4:10 PM, an interview was conducted with resident 2. Resident 2 stated that the facility did not have enough staff available. Resident 2 stated that the facility had no consistency with staffing and that some days the facility would have multiple agency staff who would not know the residents or what to do with them. Resident 2 stated that he would wait for an hour or longer at times for someone to help him out of the bed and to his wheelchair. Resident 2 stated that the administration was aware of this problem because residents would mention the staffing issue during resident council meetings. Resident 2 stated that often the staff would walk into a room, would turn the call light off and inform the resident that they would be back in few minutes, then never return. Resident 2 stated that the call light would have to be reactivated. 5. On [DATE] at 6:32 PM, an interview was conducted with resident 1. Resident 1 stated that the facility and residents could benefit from more staff. Resident 1 stated that he waited for his call light to be answered for up to an hour. Resident 1 stated that the staff would sometimes come into the room only to turn the light off, tell them that they would be back in few minutes and that they would never come back until the call light was reactivated or would came back few hours later. Resident 1 stated that the facility would have agency staff coming to help very often and he did not like that because the majority of the agency staff would not know the residents or how to perform certain tasks. Resident 1 stated that it was hard on the residents but also the facility staff who would need to train the agency staff and to be pulled away from their regular duties. On [DATE] at 6:00 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that if someone would call in sick or have an emergency, then they would be short staffed. RN 5 stated that the facility would use agency staff to fill openings in the schedule and that she (RN 5) would spend half of her shift training them what to do so she would not be able to finish her own tasks. RN 5 stated that they would always benefit from few extra people. On [DATE] at 3:18 PM, an interview was conducted with RN 7. RN 7 stated that she had recently hired on full time with the facility, but that she had worked as an agency nurse in the facility prior to her full time job. RN 7 stated that when she worked as an agency nurse, she had maybe 20 minutes of training before she was working the floor, and that training consisted of computer program training only. RN 7 stated that she had not had any training except for the computer program. On [DATE] at 2:30 PM, and interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had enough staff available. The DON stated that their staffing schedule was created based on the census. The DON stated that they would have agency staff from time to time, but that they tried to have less and less of them. The DON stated that it was hard to keep good employees, that they would pay their staff really well, and that people would go to work somewhere else or would quit their jobs for different reasons. The DON stated that they were always hiring. Cross Refer to F-684, F-689, F-757 and F-760 6. On [DATE] at 2:03 PM, an interview was conducted with resident council attendants. One resident mentioned We will be woken up at midnight or 1:00 AM for medications that were due at 8:00 PM. They other residents agreed. The residents stated that medications are sometimes 5 hours late. The residents stated medications that were supposed to be given before breakfast were given at lunch. All residents agreed with above statements. | 2020-09-01 |