cms_UT: 87
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 87 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 689 | E | 1 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined for 2 out of 31 sampled residents that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision to prevent accidents. Specifically, a resident was observed to burn her hair, drop a lit cigarette down the inside of her smoking apron, and then smoke without an apron in place. Additionally, a resident was transferred with a one person assist when they were assessed as requiring two people. Resident identifiers: 9 and 38. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 1:00 PM, resident 38 smoking was observed smoking. The resident was observed wearing a smoking apron. The resident was supervised by the Social Service Worker (SSW), and the SSW was observed to cue the resident when to ash the cigarette. The resident was observed to be crying, agitated, and stating hurt during the smoke break. The resident was observed to lean forward in her wheelchair (WC) multiple times while holding her cigarette, and her arm and upper body movements appeared spastic. The resident's hair braid was observed to swing forward through her cigarette butt two times, singeing her hair, before the SSW noticed. The SSW was then observed to hold resident 38's hair away from the cigarette. The SSW was then observed to go back inside the building leaving resident 38 to be supervised by the Medical Records staff. The Medical Records staff was observed to stand in front of resident 38 while talking to another resident, and their attention was not focused on resident 38. Resident 38 was then observed to propel herself forward in her WC causing the resident's apron to be caught in her WC legs. This resulted in her upper body being pulled forward towards the ground. The resident was stabilized and the apron was untangled by the Medical Records staff. The resident's cigarette was observed to fall out of her mouth and down the front of her in between the apron and the resident's clothing. The Medical Records staff was observed to frantically search for the missing lit cigarette. The lit cigarette was observed to fall to the ground in front of resident 38. [MEDICAL CONDITION] observed on resident 38. On 6/18/18 resident 38's electronic medical records were reviewed. Review of the Smoking Screen Assessment on 6/15/18 revealed that resident 38 has cognitive loss, dexterity problems, communication deficits, the resident can not extinguish and dispose of the ashes safely, the resident has tremors or uncontrolled movements, and the resident has a condition that could result in a burn or fire to themselves. The Assessment documented that the resident could not light her own cigarette and required a smoking apron while smoking. Review of the Care plan for smoking revealed, .(resident's name) chooses to smoke. Staff have educated on smoking apron and have offered apron during designated smoking times. Refusing to wear apron despite education. (resident's name) is not safe to light her own cigarette related to spastic involuntary movements- staff light cigarette for her; needs supervision during smoking. Interventions identified on the care plan include the following: a. Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station. b.Instruct (resident's name) about smoking risks and hazards and about smoking cessation aids that are available. c.(Resident's name) requires SUPERVISION while smoking, staff to light her cigarette for her. d.(Resident's name) smoking supplies are stored in med room. e.Observe clothing and skin for signs of cigarette burns. Notify LN (licensed nurse) immediately if present, f.The facilities smoking policy was reviewed and accepted by (resident's name) and her family. g.Watch for proper oral hygiene. On 6/19/18 at 3:05 PM, resident 38 was observed smoking without an apron on. The cigarette was lit and resident 38's hair was observed to make contact with end of the lit cigarette, singeing her hair. The Medical Records staff was then observed to go inside the building and obtain an apron. Resident 38 was left unattended with a lit cigarette. Resident 38 was observed to state hair to the Medical Records staff. The Medial Records staff then tucked the residents hair into her shirt, and re-secured her hair away from her face. The Medical Records staff was observed to instruct resident 38 to give her cigarette to resident 31 to extinguish. An immediate interview was conducted with the Medical Records staff. The Medical Records staff stated that the supervised smoking procedure was to place the apron on the resident prior to lighting the cigarette, and she forgot to because the resident makes her so nervous. On 6/20/18 at 1:57 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated she had supervised resident 38 during smoking previously. CNA 6 stated that smoking supervision was not assigned and it was whoever was available. CNA 6 stated resident 38 wore an apron for smoking. CNA 6 stated that she made sure that resident 38 does not tip over or burn herself during the smoking break. CNA 6 stated that resident 38 needs supervision for everything. On 6/21/18 at 8:25 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 38 was a supervised smoker. The DON stated that the resident required an apron for smoking and that it was applied prior to lighting a cigarette. The DON further stated that staff are to help her extinguish the cigarette, and attend to resident 38 the entire time she was smoking. The DON was informed of the observations of resident 38 smoking without an apron, singeing her hair and dropping a cigarette down the front of the apron. No additional information was provided. 2. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. On 11/15/17, a care plan related to resident 9's risk for falls was developed. The care plan documented that resident 9 had a history of [REDACTED]. The goal developed was, (Resident 9) will not sustain serious injury through the review date. On 3/1/18, an intervention of Staff educated to assist with two assist for transfers/gait belt; encourage the use of the walker was implemented. On 5/28/18 at 2:16 PM, a facility nurse documented in a progress note, Was called to resident room by the aid. Resident laying on the floor by her recliner. No injuries. Residnet (sic) did not hit her head, she was lowered to the floor during transferring from the wheelchair to her recliner. Staff to continue to monitor. On 5/30/18 at 11:18 AM, a facility nurse documented in a progress note, IDT (Interdisciplinary Team) Fall Review: Refer to PT (Physical Therapy) to increase strength to BLE (Bilateral Lower Extremities) and improve safety with transfers. (Note: There was not an investigation into the fall to ensure that the care plan was followed and interventions to prevent resident 9 from falling were implemented.) On 6/19/18 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to determine who was transferring resident 9 at the time resident 9 was lowered to the floor or whether two staff members were transferring resident 9 as care planned. | 2020-09-01 |