| 5 |
SEA VIEW NURSING HOME |
485000 |
7500 BOLONGO BAY |
ST THOMAS |
VI |
802 |
2010-08-25 |
323 |
L |
0 |
1 |
MZE911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents . This finding incorporates both environmental and quality of care practice. The environmental finding has the potential to place all residents in the facility at risk and constitutes Immediate Jeopardy. The Findings are: 1. The facility is a 40 bed SNF/NF facility built on a mountain top. One wing of the facility lacks a safe means of egress for evacuating residents in an emergency. The exit doors leading from this wing open onto a steeply sloped incline with a narrow cemented walkway which runs alongside the mountain cliff. The walkway does not have protective rails or barriers of any kind. Any resident wandering in this area who has an unsteady gait or makes a misstep is at risk of falling off the mountain cliff. This walkway is easily accessed from two other exit doors. Additionally, the facility has a number of residents who were identified as wanderers. Several residents were observed to wander outside of the building unattended by staff on various days of the survey from 8/19 through 8/25/10. One resident was observed taking a walk unattended on 8/20/10, at approximately 2:00P.M., and one resident was observed to sit outside of one of the exit doors unattended at various times throughout the day on all survey days. Meetings were held with the Facility owner, the Chief executive Officer, the Administrator and Director of Nursing Services on 8/19/10 at 12:35P.M. to discuss the Immediate Jeopardy findings. The Owner immediately arranged to correct this problem. On 8/20/10 at 11:00A.M. a construction company was observed on site preparing the grounds for construction. The construction includes the following: 1. Construction of a safety concreted ramp leading from the exit doors to the walkway. 2. Expansion of the walkway. 3. A safety Barrier along the walkway. 2. Based on interviews and review of medical records, it was determined that the facility failed to appropriately supervise one of ten sampled residents who sustained a fall and resultant hip fracture which required surgical intervention and pain management. This deficient practice is evidenced by the following: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. As a result, the resident required a Right Hip Hemiarthroplasty ( total right hip replacement). The Minimum Data Set Assessment for mobility and transfer reveals that the resident requires supervision and personal assistance for transfers and ambulation. The resident's April 2010 Fall Risk Assessment identified her as a high risk for falls with a score of 13. According to the instructions on the Falls Risk form, a total score of 10 or above represents a high risk. A review of the facility ' s report of this Incident revealed that on 5/10/10 at 3:15 P.M., this resident fell out of her wheel chair in the lounge. The Incident report documents there were no witnesses to the incident. The report also reveals that no follow-up investigation of the incident was planned, the resident's next of Kin was not notified, and no visible injury sustained. The resident's Care Plan for falls specified that fall assessments should be done quarterly and PRN. There was no evidence of re-assessment of the resident or revision to the care plan following this incident. The CNA Care Plan for the resident also did not reflect any revisions. A second incident report dated 7/11/10 at 6:30 PM, documents that the resident was found on the floor of the bathroom in her room. Section D of the Incident Report, records: The resident was at high risk for falls. She was admitted with burns to her feet and was unable to ambulate for several months. Once her feet were healed, she wanted to ambulate, but she was very weak and required a walker with assist of one. Interviews conducted on 8/20/10, 8/23/10, and 8/24/10, with the Activities Director, Dietician, CNA's, and Nurses from various shifts, confirmed that staff were aware of this resident's risk factors and need for assistance with transfers, ambulation and toileting. Three of the staff members noted that these requirements are the same as when she was a new admission. In an interview with the surveyor on 8/24/10 at 1:20 PM, the Director of Nursing (DON) acknowledged that a falls risk re-assessment should have been done after the May 2010 incident, as well as revisions to the care plan prior to the second fall on 7/11/10. When the resident's care plan was reviewed on 08/24/10 , no new interventions for fall prevention had been added. The facility ' s Policy and Procedures on Fall Prevention, Revision date April 23 2010, reads under section #2 as follows: ? Assign resident to be monitored frequently to prevent falls. ? Apply bed and chair alarms to alert staff when resident is moving. The curriculum used as a part of the facility's mandatory in-service training on fall prevention (given quarterly) provides the following instructions: Interventions for fall prevention ? Never leave at risk residents unattended ? Wander guards on wrist or ankle ? Bed alarms when resident is getting out of bed. There was no evidence that these interventions were implemented for resident #1 on admission, or after the May 2010 fall, nor after the 07/11/10 fall when the resident sustained [REDACTED]. |
2017-01-01 |