cms_UT: 8
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 744 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined for 1 of 30 sampled residents that the facility did not provide the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with [REDACTED]. Resident identifier 68. Findings include: Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/09/18 at 10:43 AM an observation was made of Certified Nursing Assistant (CNA) 3 providing incontinence care to resident 68. An observation was made of resident 68 hitting and biting CNA 3 during the incontinence care and nearly striking CNA 3's face. CNA 3 was observed to continue with the care until finished. Resident 68 was observed to be agitated and combative the entire time. An immediate interview was conducted with CNA 3. CNA 3 stated, The resident gets agitated a lot. CNA 3 stated that the nurse usually gave resident 68 medication to calm her down, and further stated that nothing else calms resident 68 down. On 1/9/18, resident 68's electronic medical records was reviewed. Review of resident 68's orders revealed the following: a. [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligram (mg) by mouth two times a day. b. Non-Pharmalogical interventions done: 1. Redirection, 2. Speak to/Approach in a calm manner, 3. Reposition, 4. Offer snacks/fluid/milk, 5. Assess for pain, 6. Provide a quiet environment, 7. Encourage to express feelings, 8. Take to activities, 9. Provide reassurance ([MEDICATION NAME]) every shift. Review of the progress note on 6/25/17 revealed, Resident was kicking and grabbing at staff to get their attention. Staff attempted redirection, giving snacks, and giving her an activity, resident continued to come to staff and kick and grab. Review of care plan revealed the following focus areas and interventions: a. Has impaired cognitive function/dementia with an intervention of refer to MY WAY plan of care located in resident's room. b. Has Altered behavior pattern and ineffective individual coping as evidenced by (AEB) easily startled by sounds or touch within environment, agitation, anxiety, tearful, combativeness related to Dementia Alzheimer's late stage. Interventions include; allow rest/nap between meals as desired by resident to reduce combative and anxious behavior, Ensure resident can see you before you touch or move her, provide a quiet environment as much as possible, explain cares prior to starting cares in unhurried manner, may need to go for a walk in wheelchair when anxious to calm down, prefer her door closed when resting in bed, monitor/record/report to Medical Doctor labile mood or agitation, and See MY WAY form to implement individualized request from resident daily which includes sleep cycle, Activities of Daily Living (ADL's) and dining preference. Review of resident 68's MY WAY plan revealed the following preferences: a. Bathing every other day and shower with a wash rag. Order: Head (face), Chest, Arms, Back, Groin, Legs, Feet b. Toileting preference is to give me privacy c. Dining/Eating preference are: I feed myself with both hands and I drink liquids throughout the day d. Dressing preference are sleep in pajamas or night gown, I stand and sit while I dress, and I don't wear a bra. e. Schedule is to sleep at 7:00 PM f. Assistive devices are a wheel chair g. Hobbies are I would rather do individual activities. Review of Interdisciplinary Team (IDT) notes revealed no documentation to show behaviors of hitting, pinching and biting were discussed. On 1/16/18 at 2:40 PM, an interview was conducted with CNA 7. CNA 7 stated that the resident was feisty and hits and pinches when transfers or incontinence care are being provided. CNA 7 stated that she usually stops the activity that is upsetting the resident and comes back later to finish with the care. On 1/16/18 at 2:45 PM, a repeat interview was conducted with CNA 3. CNA 3 stated that the resident gets agitated and hits, slaps, pinches and bites. CNA 3 stated that the behaviors were towards staff and other residents. CNA 3 stated that the interventions to calm her down were to lay her back down in bed and the nurse will give her medication. CNA 3 again stated that no other interventions calm resident 68 down. On 1/16/18 at 2:55 PM an interview was conducted with CNA 4. CNA 4 stated that resident 68 hits staff and other residents and that I thinks she (resident 68) likes to hit people. CNA 4 stated that the interventions to calm the resident down were back massages, hand massages and laying her down in bed. 01/17/18 at 7:42 AM interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that the MY WAY plan was something that the previous corporation implemented and was not currently an intervention. CRN 1 stated that the MY WAY plan was essentially a preference care sheet based on an interview conducted with the family upon admission. On 1/17/18 at 8:00 AM a repeat interview was conducted with CRN 1. CRN 1 stated that dementia training was provided annually and upon hire through a computer based training and was scheduled for 1/25/18. CRN 1 further stated that the facility also utilized the MY WAY plan with those staff members who were aware of it and that the plan has additional training with it, but knows that the new Director of Nursing (DON) had not provided the training because she was unaware of the plan. CRN 1 was informed of the observation between resident 68 and CNA 3. CRN 1 stated that she would immediately provide education to CNA 3. | 2020-09-01 |