cms_WV: 11393
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11393 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 323 | G | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have "bruising each side of her nose" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was "slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)." - On 11/25/10 at 8:30 p.m., a report stated, "Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash." - On 11/27/10 at 5:00 p.m., another report stated, "CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted." No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., "CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..." - On 07/29/10 at 6:00 a.m., "Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct." - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), "Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..." Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: "Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms." The goal associated with this problem statement was for this resident to "wander safely and have no injuries r/t falls through review date." Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. - 7. Resident #24, when asked if he was bothered by wandering residents during an interviewed 12/06/10 at 12:15 p.m., stated that yes he was and that Resident #20 had wandered into his room the previous night, taken his soft drink, and dumped it into the sink. When asked what he did in response, he stated that he "took ahold of him (Resident #20)" then a nurse came in and told him he couldn't do that. When asked if a barrier-type stop sign had ever been offered to him to deter wanderers from entering his room, Resident #24 stated, "No." - 8. Following the interview with Resident #24, the facility was toured and observation found only two (2) barrier-type stop signs in use on two (2) resident rooms, but the devices were not attached in a manner that would deter a wanderer; in both cases, the banners were hanging on one (1) side of the doorway instead of being secured across the doorways as intended. On the second day of the investigation (12/07/10), observation found three (3) such barriers in place. The third barrier was noted to be across the entrance to Resident #24's room. When interviewed again on 12/07/10 at 11:00 a.m., Resident #24 stated he asked staff for the barrier after speaking with this surveyor the previous day. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his "head gashed open". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found " lying on floor with roll table over him." Notes stated, "Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall." - On 10/11/10 at 9:30 a.m., the resident was "found lying on fall mat in his room (sic) assisted back to bed." - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. "fell on R knee and R elbow." - On 10/14/10 at 10:15 a.m., "Resident exited facility through Activity Room Door. Brought back in without difficulty." - On 10/19/10, "Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor." - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., "Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor." - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the "grate" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. "Resident still had his support hose on." - On 11/15/10 at 10:05 p.m., "Heard resident yelling, found resident laying on the floor in resident's room." The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. "Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed." - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, "Not sure if (fall was) from bed or chair." The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, "Resident's bed alarm ringing and was on the floor skin tear to R (right) knee." - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. Observation, at 2:34 p.m. on 12/07/10, found Resident #20 lying on his bed. There was no body alarm present in the room, and the bed alarm was disconnected. This observation was confirmed by the DON, who stated, "It can't work if it's not connected." - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to psychotropic drug use and he had the potential for "adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care." Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a head laceration to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: "High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior." The goal related to this problem statement was: "Resident to remain safe, free from injury." Approaches to assist the resident in attaining this goal included: "Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed." The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for "no known reason" and was noted to have said, "I'm gonna give him one." The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 "punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye." - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others. | 2014-04-01 |