cms_WV: 11358
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11358 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 323 | G | 777711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as "Nose Deformity /c (with) Bruising & Nose bleed". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading "Protective Devices" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., "Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip." There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., "Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)." Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., "Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., "Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit." Under the heading "Description of Injury" was written "2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt." Under the heading "Protective Devices" the author noted a reclined geri-chair was in use at the time of the fall due to "freq. (frequent) falls". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a "Right to Fall Policy"; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: "Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness." The goal associated with this problem statement was: "Resident will have < (symbol for 'less than') 2 falls per day x 90 days." The interventions intended to assist the resident in achieving this goal were: "Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. " There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. | 2014-04-01 |