| 2 |
PINE LODGE |
515001 |
405 STANAFORD ROAD |
BECKLEY |
WV |
25801 |
2018-02-09 |
656 |
D |
1 |
0 |
3JZJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and Center (VAMC) staff interviews, the facility did not implement interventions in Resident #92's care plan to meet the resident's preferences and address the resident's medical, physical, mental and psychosocial needs. This pertained to the care area of activities of daily living (ADL), concerning shaving Resident #92 daily. This was true for one (1) of three (3) care plans reviewed for resident's totally dependent for ADL care. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Observations, on 02/05/18 at 11:55 AM., revealed Resident #92 appeared clean, without any body odors, Foley catheter was draining to drainage bag on bedside. The resident was lying in his bed, eyes closed with hair stubble noted on resident's chin. The resident has a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands, and it was within reach of the resident. On 02/06/18 at 9:05 AM, review of grievance and concerns revealed on 09/12/17 the resident complained . he was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face, . Resolution to these concerns were completed by 09/27/17 with staff being educated to shave resident daily, Kardex being updated with the resident's preferences. A Kardex provides specific instructions, for the nursing assistants, concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed under the skin care focus instructions written as is ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. On 02/08/18 11:03 a.m., an interview with VAMC SW#302 revealed she reported a situation concerning Resident #92 because she is a mandatory reporter and had notified the facility of the allegations. VAMC SW#302 said she first saw the resident, on 12/26/17, after being asked by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304 to see the resident. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 described the resident was alert and oriented and the ambulance crew told VAMC SW#302, the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew told VAMC SW#302 his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. |
2020-09-01 |