cms_UT: 71
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 71 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 323 | G | 0 | 1 | WP7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for 1 of 25 sample residents, the facility did not ensure that each resident was safe from accident hazards. Specifically, a resident sustained [REDACTED]. The findings were cited at a harm level due to the resident not having adequate supervision to prevent falls. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/22/17 at approximately 9:10 AM, an observation was made of resident 35 laying in bed. The bed was not in the low position. Certified Nurse Assistant (CNA) 1 who was in the room confirmed that bed was not in lowest position. CNA 1 lowered the resident's bed approximately 12 - 18 inches to the lowest possible position. CNA 1 stated that staff will lower resident's bed but resident had access to bed control and would often return the bed to a normal height. Resident 35's medical record was reviewed on 6/22/17. Review of the admission MDS (Minimum Data Set) Assessment, dated 2/13/17, revealed that the facility staff assessed resident 35 as requiring limited assistance with a one person physical assist for transfers, ambulating, toileting, and bed mobility. The facility staff also identified that resident 35 had sustained falls in the last 2-6 months prior to admission. A Care Area Assessment (CAA) triggered for falls. The facility staff documented that the care area would be addressed in a care plan. Review of resident 35's care plan revealed an Activities of Daily Living (ADL) Self Care Performance Deficit care plan that was initiated on 2/7/17. The goal developed was Will safely perform Bed mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) (sic) with modified independence) through the review date. The interventions developed to achieve the goal included: Occupational (OT), Physical (PT), Speech-Language Therapy (ST) evaluation and treatment to establish functional maintenance program per physician orders, Requires extensive assist x 2 (two person assistance) for adls, .Encourage to use bell to call for assistance. 1. On 2/5/17 at 3:45 PM, an incident report documented, CNA found resident sitting in a corner of her room, crying stating that she slipped and hit her head and shoulder on her closet door. unsure of what she was doing. On 2/5/17 an actual fall care plan was developed. The goal developed was Will resume usual activities without further incident through the review date. The intervention developed was to replace the quad can with a walker. 2. On 2/21/17 at 9:00 AM, an incident report documented, Pt (patient) was getting up from chair at the dinning (sic) table. Pt's leg hit the sit (sic) of the chair, hitting the chair out from under pt and causing pt to lose her balance. Pt fell to the right side. S/S (signs and symptoms) of increased pain to right shoulder noted at time of fall. Skin remains intact. Pt states right shoulder does hurt more after the fall. Staff there with pt at the time of fall. Additionally, the facility staff documented, Her pants were too tight and she could not bend and stand up correctly. (Note: Resident 35 required limited assistance with a one person physical assist with dressing.) The investigation into the incident was completed. The facility staff documented, She was walking with clothes on that impaired balance and fell . The interventions that were in place prior to the fall included: Call light within reach, frequently used item within reach, clear pathways, ensure non slip footwear, use of walker. (Note: The actual fall and ADL care plan did not include interventions for frequently used items within reach, clear pathways or ensure non slip footwear.) The new intervention documented on the incident report was Family to remove clothes and replace with clothes that is appropriate. The actual falls care plan was updated to include the new intervention of proper fitting clothes and provide pants that are not tight and inhibit function. 3. On 2/23/17 at 3:02 PM, an incident report documented, Floor (sic) by PT and CNA face down on the floor next to her bed, yelling and crying. Noted to be bleeding from her nose. Stated that she was trying to get up, rolled out of bed. The investigation into the incident was completed. The facility staff documented, She was attempting to self transfer and toilet self when she lost balance and fell from bed. The new intervention to be implemented was medications review/labs (laboratory). On 2/23/17 at 3:11 PM, the facility Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN) Supervisor documented in a progress note, Found by PT and CNA after hearing a loud bang, found resident face down on the floor crying and screaming, noted that she was bleeding from both nares are (sic) swollen and tender with some discoloration. Has full ROM (range of motion) of all extremities, neuro (neurological) checks WNL (within normal limits) also VS (vital signs). Ice applied to nose scant bloody drainage, in bed with HOB (head of bed) up. Stated that she was trying to get up rolled out of bed falling onto the floor. Bed was in low position, call bell was clipped to her blankets with in easy reach. Daughter called message left to call facility. MD (Medical Director) and ADON (Assistant Director of Nursing) aware. On 2/23/17 at 6:00 PM, the facility LVN/LPN Supervisor documented in a progress note, NP (Nurse Practitioner) (name redacted) went into eval (evaluate) residents (sic) face/nose after fall, found her to be unresponsive this nurse also no reaction to sternal rubs, both pupils sluggish, drooling on right side, after approx. (approximately) 10 minutes became more alert, cognitively slow in response, after 30 minutes much brighter. NP requests eval (evaluation) at ER (emergency room ), daughter aware to meet her at the ER at (name of local hospital) EMS (Emergency Medical Services) called transported to (name of local hospital), report called to ER. Review of the hospital records indicated that resident 35 had a seizure with a low phenobarbital and valproic acid levels. The actual falls care plan was updated to include the new intervention of medication/labs. 4. On 2/28/17 at 3:45 PM, an incident report documented, Pt. found on floor of room, sitting in front of wc (wheelchair) facing the window. Pt had been in the DR (dining room) and pt took self in wc from the DR to pt's room. Brief wet with urine at time of fall. Pt reports pain to shoulder and lower back. No new skin concerns noted at time of fall. The investigation into the incident was completed. The facility staff documented, She attempted to self transfer and lost her balance. The new intervention to be implemented was to review the wheelchair for safety. The actual falls care plan was updated to include the new intervention of eval (evaluate) w/c (wheelchair) for safety. 5. On 3/15/17 at 8:15 AM, an incident report documented, CNA found resident on floor, calling out. This nurse found resident laying on left side on the floor leaning against the door jam. States that she did not hit her head then recounted this stating that she did. stated (sic) that she got up to go to the bathroom without help. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. She attempted to take herself to the bathroom and lost her balance and fell . The new intervention to be implemented was medication review and lab ordered. The actual falls care plan was updated to include the new intervention of seizure med (medication) review/labs re-education. 6. On 3/20/17 at 1:00 PM, an incident report documented, Pt found on floor laying face down along side the (sic) bed. Pt snoring at the time pt was found. Easily awaken. No noted injury. Call light within reach of pt, not activated. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. Pt was found laying on the floor with pillows under head, awoke easily and voiced no new complaints. The new intervention to be implemented was Encourage pt to have bed in lower position. 7. On 4/7/17 at 10:49 PM, an incident report documented, Found PT (patient) sitting on floor. Assessed cognitive function and assessed body. No abnormal findings. She was sat into bed. Neuro checks per facility protocol. MD notified. PT (patient) states she was trying to get into bed and she slid to the floor. The investigation into the incident was completed. The facility staff documented, Pt was found sitting on the floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c. The new intervention to be implement was Pt will be moved to room closer to nurse station as well as to bed which will make pt more visible to staff. On 4/7/17 at 10:52 AM, License Practical Nurse (LPN) 1 documented in a progress note, PT was found in her room. She stated that she had slid down her bed to the floor while trying to get into bed. Full assessment conducted yielding no notable concerns. PT placed into bed. Neuro checks per facility protocol. MD notified. On 4/8/17 at 10:23 PM, LPN 2 documented in a progress note, Patient returned from ED (emergency department). Patient has soft cast splint in place. Splint is to be kept on until follow up ortho (orthopedic) appointment in 1-2 days. Patient is to use w/c or crutches for mobility. On 4/10/17 at 11:18 AM, the ADON (Assistant Director of Nursing) documented in a progress note, IDT (Interdisciplinary Team) review of fall from 4/7/2017. At time of falls Had (sic) no skid socks on, no shoes, denied pain at time of fall, post fall pain 3/10 call light not activated. intervention to help prevent falls was to move closer to rear nursing station in a bed and re educated (sic) to call lights, items in reach and frequently used items, bed in lower position. Pt started to have swelling noted to left ankle and pain, x-ray was obtained and noted to have fx (fracture) to left ankle. family (sic) was notified upon x ray results She was sent to ER (emergency room ) for eval and treatment Review of hospital emergency room records, dated 4/8/17 at 7:01 PM, documented that upon x-ray of left ankle resident 35 sustained a distal fibular fracture with adjacent soft tissue swelling. A review of resident 35's ADL charting dated 4/1/17 through 4/16/2017 revealed that staff was not providing a two person transfer assistance during this time frame as documented in resident's care plan. Resident 35's actual falls care plan was not updated to include additional interventions. On 6/21/17 at approximately 1:10 PM, an interview was conducted with LPN 1. LPN 1 stated that on 4/7/17 he observed resident 35 sitting on the floor of her room with her back to the bed and legs extended outward. LPN 1 stated that he assessed the resident for pain, neurological status and muscular problems. LPN 1 stated that resident began to cry and when questioned as to why she was crying, resident stated she that she was scared because she had fallen. LPN 1 stated that the resident continued to deny pain. On 6/21/17 at approximately 1:40 PM, CNA 1 was interviewed. CNA 1 stated that resident 35 was provided with a low bed, call light in reach, bedside table and frequently used items in reach. CNA 1 stated that fall happened after breakfast and that resident's demeanor after the fall was the same as before the fall. CNA 1 stated resident did complain of pain in her leg and that the pain was reported to the nurse. (Note: This was resident 35's seventh fall in two months. The facility staff did not increase resident 35's supervision to prevent accidents from occurring.) 8. On 5/5/17 at 6:15 PM, the ADON documented in a progress note, resident has an assisted fall while being transferred from w/c to bed, was on bed and slide (sic) off, bed in lower position and lost her footing. No injury noted , (sic) no bruising, daughter called and left message fall (sic) at 6:12 pm, non slide socks on, walker in front of resident. Did not hit head per c.n.a On 5/5/17 at 8:46 PM, the ADON documented in a progress note, Resident had a fall while being transferred into bed was sitting on bed and slipped off, staff assisted , (sic) did not hit her head, walker was in front of her and c.n.a. turned to push w/c. Daughter called message left. No injury. Did not hit head. Will have two people assist when resident is sleepy. (Note: Resident 35's initial ADL's care plan indicated that two people were to transfer resident 35.) The actual falls care plan was updated to include lips (unknown) assessment-requires 2 person assist r/t (related to) cast/behaviors. (Note: The initial ADL's care plan indicated that resident 35 was to have a two person assistance with transfers.) 9. On 5/9/17 at 8:20 PM, a licensed nurse documented in a progress note, At about 2020 (8:20 PM) the nurse heard patient yelling for help to find patient on the ground with back against the bed. Bed was at it (sic) lowest position. Patient stated that she was trying to get herself in bed. Patient stated she took of (sic) her shoes and lowered the bed to the ground and tried to get in. No injuries were noted. Patient states her knee hurt but was able to do full ROM (range of motion) without pain. Call light was in reach. DON, family and MD were notified. On 5/10/17 at 5:21 PM, the DON documented in a progress note, IDT (interdisciplinary team) review of fall on 5/5/17 (and) 5/9/17.Pt was assisted to the floor as she began slipping and aide lowered her to floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c.New intervention: lips (unknown) assessments. The actual falls care plan was updated to include call light education and return demonstration. On 5/11/17 at 4:24 PM, the DON documented in a progress note, Spoke with (resident 35's daughter) that I think that this is behavior related as she had pants folded on bed, w/c cushion on bed and she was sitting on the floor but insisted she fell from bed. Pt reports that she activated call light but it was not in on. Call light was changed to bulb call light. Pt will not tell this nurse any further details of incident. CNA reported she attempted to go in to do vitals on pt and she refused to have vitals taken at that time. Daughter reports that she had conversation with pt earlier today, states she thinks mom may be in bad (sic) mood r/t her inability to visit r/t vital illness. States her mother is manipulative and act (sic) to get attention. 10. On 5/11/17 at 4:30 PM, the ADON documented in a progress note, Resident was on floor sitting next to bed, w/c was slightly away from bed with wheels locked and pressure reduction cushion set on bed, her pants and shirt were nicely folded. It appears that resident set herself on floor. No injuries noted she was crying and saying that she had her light on, call light not on , (sic) no socks on feet. unsure how resident could have slid out of bed with clothes folded on bed where she would have had to slide out. She stated that she slide (sic) out of bed. It appears to be possible behaviors , (sic) when speaking to daughter by DON she said she had not been up here due to being not there and that her mom had called her today and that she also though (sic) behaviors. No injuries , (sic) no pain more anxiety. On 5/12/17 at 7:02 PM, the DON documented in a progress note, IDT review of fall on 5/11/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: new bubble call light placed in room. The actual falls care plan was updated to include bubble call light. 11. On 5/21/17 at 9:17 PM, a licensed nurse documented in a progress note, At about 1845 (6:45 PM) Nurse was called to patients room to find patient on the ground in front of her dresser. Patient was on her but (sic) facing the door with non-slip socks on. Patient has a small scratch on the right side of her nose that may or may not be r/t fall. Patient has two bumps on the back of her head. No other injuries were noted. Patient neuro assessment was started and VS (vital signs) have remained normal. Family, DON and NP were noted. On 5/22/17 at 4:17 PM, the DON documented in a progress note, IDT review of fall on 5/21/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: Eval (evaluate) w/c for anti-tips. The actual falls care plan was updated to include eval for anti-tips on w/c (pt r/t weigh (sic) tips w/c despite anti-tips bars as she will lean to side. Given reacher. 12. On 6/3/17 at 11:12 AM, the LVN/LPN Supervisor documented in a progress note, Heard resident calling out found resident sitting on floor at edge of bed with w/c tipped, stated that she was trying to look in her hamper 'scootted (sic) to close to the edge' assessed for injury none noted, assisted back into w/c . On 6/5/17 at 12:28 PM, the DON documented in a progress note, Pt was found sitting on floor. Yelling out for help.New intervention: Room moved . The actual falls care plan was updated to include room moved. 13. On 6/4/17 at 10:59 AM, the LVN/LPN Supervisor documented in a progress note, Early this am (morning) was yelling in her room that she wanted to get UP NOW!, explained that she needed to wait a few minutes as her CNA was finishing with someone else. 'I don't care tell her to get her butt in HERE NOW! again reassured that she would be in, several minutes while this nurse was in the room the CNA came and got her up, she then attempted to get something from the vending machine, was mad that she could not. She then went down into the dining room and started crying because another resident in her 'Spot' and that no (sic) cares that she had to wait this am (morning). after breakfast went into her room, walked into bathroom without assist then fell on to right side with her face turned to the floor, noted to have a discoloration on forehead and small reddened area on her right side, had full ROM WNL assisted up into w/c X 4 (four) persons as she will NOT hold her own wt (weight). VS and Neuro checks good, assisted into bed with call bell and bed controls in reach. Shortly after CNA found resident laying sideways in her bed attempting to get up again, stated that she wanted to get up, asked why she did not call 'I don't need help' assisted into w/c. at nurses desk now. Daughter called about fall no answer message left to call facility, DON and PA (Physician's Assistant) aware of fall. On 6/5/17 at 12:34 PM, the DON documented in a progress note, IDT review of fall on 6/4/17.Pt was found laying on floor. Yelling out for help. Earlier in the day she told 'CNA' let (sic) see what happens when I fall as a response to aide helping get roommate dressed before her.New intervention: Dipstick ua (urinalysis) . The actual falls care plan was updated to include ua dipstick. On 6/5/17 at 10:49 AM, the DON documented in a progress note, Ua negative. On 6/6/17 at 4:17 PM, the ADON documented in a progress note, .has had some increased behavior and will tell staff that she is going to fall if she is not treated like their mother. She has some confusion will yell out at times and just scream, not r/t pain. She rated her pain 5/10 sometimes, has some SOB (shortness of breath) with activity, laying flat and rest ,is (sic) on oxygen when in bed. she did have a fall with fx (fracture). She remains a fall risk to (sic) despite intervention. Is ext (extensive) two person to stand transfers and toilet, ext for all adl functional cares, she could assist with dressing and washing face but needed assist and cues to assist.She could recall two word with cue sock, bed , (sic) blue knew yr (year) new month not day.She has confusion and other times she can answer questions from the past , (sic) knows staff names at times.has weakness in bialt (sic) (bilateral) legs and UE (upper extremities. 14. On 6/8/17 at 9:16 PM, a licensed nurse documented in a progress note, I was called into the patients bathroom by another nurse. Pt was lying on her R (right) side on the floor of the bathroom. there were no visible injuries, and no new c/o (complaints of) pain. at the time. pt's call light was on, aid/staff members were attempting to answer the patients call light, when the patient became anxious and tried to stand on her own. pt has been educated numerous times by staff and family to wait for help with cares. pt verbalizes understanding but continues to be noncompliant. pt was assisted back into her w/c, assessed further for any injuries, pt was cleaned up, and helped into bed for the evening. (Note: This was resident 35's fourteenth fall since her date of admission.) On 6/9/17 at 6:50 PM, the DON documented in a progress note, IDT review of fall on 6/8/17.Pt was found sitting on floor in bathroom. Yelling out for help. She had attempted to assist herself off of toilet.New intervention: Toilet Riser don't leave unattended in bathroom . The actual falls care plan was updated to include dont (sic) leave unattended in bathroom and toilet riser. On 6/22/17 at approximately 9:00 AM, an interview with the DON was conducted. The DON stated that the facility provided staffing according to the resident acuity and that acuity was based on resident behaviors and amount of assistance need for ADL's. The DON further stated that it was difficult to determine how much assistance resident 35 would need on a daily basis because her behavior and needs differed from day to day. The DON did acknowledge that the facility was not capable of providing resident 35 with 1 on 1 supervision. The DON stated that the facility had attempted several other interventions such as moving resident 35 closer to the nurses station but resident 35 and resident 35's daughter complained which led facility to moving resident 35 back to her original room. The DON stated that one of the earliest interventions put in place by the facility was a quick response time to the call light and resident reassurance that help would be available quickly but that resident 35 would still attempt unassisted self transfers. The DON also stated that the facility attempted to provide a wedge cushion and anti-tip bars on wheelchair but resident would often remove the cushion and anti-tip bars did not prevent her from sliding forward in her wheelchair. | 2020-09-01 |