| 5689 |
LAKIN HOSPITAL |
5.1e+125 |
1 BATEMAN CIRCLE |
WEST COLUMBIA |
WV |
25287 |
2015-01-14 |
282 |
D |
0 |
1 |
RMOB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observations, the facility failed to implement the care plans for two (2) of fifteen (15) residents whose care plans were reviewed. Activities interventions were not implemented for Resident #41 and fall interventions were not implemented for Resident #15. The Stage 2 Sample was 28. Resident identifiers: #40 and #15. Facility census was 89. Findings include: a) Resident #40 Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his most recent Minimum Data Set (MDS) assessment, dated 11/12/14, found it documented Resident #40 had short term and long term memory loss and was moderately cognitively impaired for daily decision making. The MDS also documented the resident was at times resistant to care and at times and would wander on the unit. Review of the annual MDS, dated [DATE], found Resident #40 enjoyed being around animals, liked books, reading, and keeping up with the news and religious activities. Review of the current care plan, dated 11/26/14, found it documented Resident #40 enjoyed church and coloring books. The care plan also documented the resident was not able to voice his choice regarding activities, therefore staff were to anticipate his activity needs, inform him of scheduled activities, encourage him to participate, and to inform him when Church services were conducted and escort him if needed. Review of the activity calendar for (MONTH) (YEAR) revealed on 01/12/15 at 3:00 p.m. and on 01/13/15 at 10:30 a.m., the activity calendar identified individual and small group activities were to take place on the units. According to observations on these dates and times, there were no activities conducted on C unit due to the fact the activity staff for the C unit had called in ill. On 01/13/15 at 10:30 a.m., the activity calendar indicated individual and small group activities were to take place on the units. There were no activities observed being provided at that time. Review of the (MONTH) (YEAR) activity calendar revealed Church services were offered on 01/04/15, 01/08/14, and 01/11/15. There was no evidence Resident #40 attended Church service on any of those dates. The activity calendar also indicated one-on-one activities were to be provided on the unit on 01/05/15, 01/07/15, and 01/12/15. There was no evidence Resident #40 was invited or attended these activities. Observations on 01/12/15 at 9:30 a.m., 1:10 p.m., and 3:30 p.m. revealed Resident #40 was in his wheelchair on the unit, but was not participating in any activities. Observation on 01/13/15 at 2:05 p.m. revealed he was in bed. Observation on 01/14/15 at 9:30 a.m. revealed he was in his wheelchair on the unit An interview with Health Service Trainee #141 on 01/13/14 at 2:40 p.m. revealed she was not aware of any activities that occurred on the unit that Resident #40 attended. She stated she had never seen Resident #40 leave the unit during her shift from 7:00 a.m. until 3:00 p.m. to attend activities. She also stated she had never seen activity staff come to the unit and do one-on-one activities with the resident. She stated he usually spent the day in his wheelchair or in his bed. She said he was mobile in his chair, but stated she was not aware of him being involved in any type of activities. Interview with Activity Staff #129, on 01/13/15 at 2:05 p.m., revealed she was not the staff member responsible for providing one-on-one activities for the residents on the C unit. She indicated Activity Staff #29 was responsible for Unit C activities, but he had been off for the past three (3) days. She stated she was aware Resident #40 liked to be read to, drink coffee, and reminisce, but she was unable to provide activity logs that documented these actives were provided to Resident #40 in accordance with his current activity care plan. She stated she used to document on a standard form for individual resident participation when she conducted one-on-one activities with resident, but she did not document on that form anymore. Therefore, there was no evidence of Resident #40 attending any activities in (MONTH) 2014 or (MONTH) (YEAR) in accordance with his current care plan. This information was shared with the Director of Nursing Staff #6 on 01/14/15 at 9:08 a.m She verified activity staff should be recording any activities provided to the residents. She also verified activities should ensure the residents were provided meaningful activities in accordance with their care plans. . b) Resident #15 Resident #15 was admitted with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set, dated dated [DATE], indicated the resident had severely impaired cognition. The resident required limited assistance with transferring and walking in his room. He was independent with locomotion on and off the unit. A review of the nursing notes indicated Resident #15 had a fall on 01/03/15. The resident was ambulating without assistance and fell to the floor. A review of Resident #15's physician's orders [REDACTED]. A review of the resident's care plan, dated 06/04/14, and last reviewed by the facility on 12/09/14, found Resident #15 was identified as At risk for fall and injury related to impaired cognition, impaired mobility and [MEDICAL CONDITION] drug use, and [MEDICAL CONDITION]. The interventions included, Hipsters at all times due to high fall risk, unsteadiness on his feet, not asking for assistance and non-compliant with alarms. During an interview and observation on 01/14/15 at 9:30 a.m., Health Service Trainee (HST) #137 was questioned about the resident's fall interventions. She stated the resident was supposed to wear hipsters at all times. She looked in the resident's dresser for the hipsters. The hipster was a tan colored undergarment with padding at the hip area. She indicated the hipsters were worn under his clothing, on top of his incontinence brief. HST #137 checked Resident #15 and found he was not wearing the hipster. She stated the night shift usually got him dressed. She indicated she had not noticed he was not wearing the hipster that morning. During an interview on 01/14/15 at 9:45 a.m., HST #68 was questioned about the resident's fall interventions. She indicated the resident was supposed to wear hipsters every day because he was at risk for falls. She stated he had three (3) or four (4) pairs. She said on the weekends, they ran out of the hipsters because they were sent to the laundry for cleaning. She added the laundry staff did not work on the weekends, and they had to wait until Monday to get the hipsters cleaned. She stated on Sundays, when she dressed the resident, he usually did not have any hipsters. HST #68 stated she had asked laundry for extra pairs, but did not always get the hipsters. HST #68 indicated if she was working on Fridays, then she asked the laundry staff to clean the hipsters to ensure he had enough for the weekend. During an interview on 01/14/15 at 10:05 a.m., Laundry Worker #23 stated sometimes the staff called on Friday and asked for more hipsters. She indicated on Fridays, laundry staff delivered all the residents' clothing on all the units. She stated Resident #15 had two (2) to three (3) pairs of hipsters sent to laundry every day to be washed. She stated they kept an inventory log of the resident's hipsters. She said she was returning all of Resident #15's hipsters from the laundry at that time. A review of Resident #15's Clothing/Inventory List, indicated on 12/31/12, the resident had two (2) pairs of hipsters. On 04/28/14, the resident had three (3) pairs of hipsters. During an observation and interview on 01/14/15 at 10:26 a.m., HST #68 checked the resident's room, and indicated he had four (40 pairs of hipsters. He had three (3) pairs in his dresser, and he was currently wearing a pair of hipsters. During an interview with the Director of Nursing on 01/14/15 at 10:55 a.m., she stated she had not been informed and was not aware that the resident was running out of hipsters over the weekend. The staff had not reported the concern of the lack of availability of hipsters for Resident #15 on the weekends. |
2018-09-01 |