cms_WV: 7238
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7238 | LAKIN HOSPITAL | 5.1e+125 | 1 BATEMAN CIRCLE | WEST COLUMBIA | WV | 25287 | 2014-07-23 | 323 | G | 1 | 0 | R9GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident environment was as free from accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. This was true for one (1) of five (5) sampled residents reviewed for accidents Resident #43 was identified at a high risk for falls on admission. The facility failed to implement interventions to reduce the resident's risk of falling and/or reduce risk of injury should a fall occur, until after the resident experienced a fall resulting in a nasal fracture, a closed head injury, and a cervical strain. This failure resulted in actual harm to Resident #43. Resident Identifier: #43. Facility Census: 94. Findings Include: a) Resident #43 Review of the facility's incident and accident reports, at 12:00 p.m. on 07/21/14, revealed on 07/05/14 at 12:55 p.m., while sitting near the nurses' desk, Resident #43 fell forward out of her wheelchair and landed on the floor. The report indicated the resident possibly had become tired and sleepy. The report also noted the resident had a very long torso and had a thick cushion on the seat of her wheelchair. A review of Resident #43's medical record, at 12:15 p.m. on 07/21/14, revealed a Fall Risk Evaluation was completed on 06/25/14, the date of the resident's admission to the facility. According to the assessment's scoring criteria, any score above a 10 represented high risk. The resident's score was 14. Nurse's progress notes, dated 06/25/14, revealed nursing staff were made aware the resident was at high risk for falls. The note was (typed as written): Rsdt has fall score of 14. Review of the minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/03/14, indicated the resident's Brief Interview for Mental Status (BIMS) score was 6, indicating severe cognitive impairment. The assessment indicated the resident did not walk and was only able to stabilize with human assistance in moving from a seated to standing position. She had impairment in functional range of motion of one upper extremity and both lower extremities. The assessment indicated the resident had experienced a fall in the month prior to admission. In addition, the MDS indicated the resident took 1-2 medications which could increase her risk of falls, and had 1- 2 predisposing diseases which also could increase her risk for falls. On 07/05/14 at 1:12 p.m., a nurse's note indicated (typed as written): Resident was sitting in her wheelchair on the unit when she fell forward onto the floor at approximately 1:00 p.m. Hematoma noted on mid forehead and laceration across the bridge of her nose. Resident alert. Eyes open. Moaning quietly. (Name of Registered Nurse) present and assessed resident. Directed to send to ER (emergency room ). ER notified of resident's condition and need for transfer for evaluation. EMS notified. Arrived at 1:20 p.m. Left with resident at 1:28 p.m. en route to (name of local hospital) ER. Review of the resident's ER records revealed Resident #43 was treated for [REDACTED]. She was not admitted to the hospital and returned to the facility later in the day on 07/05/14. According to the nursing home medical record, the resident's cushion was removed from her chair immediately after the fall because it was identified as a contributing factor. Additionally, the facility ordered a personal alarm for the resident to use while in her wheelchair. These interventions were put into place only after the resident sustained [REDACTED]. In an interview with the Director of Nursing (DON) at 10:15 a.m. on 07/22/14, she confirmed the fall assessment completed on the date of admission indicated Resident #43 was at high risk for falls. When asked what interventions or further assessments the facility did when the resident was identified as a high risk for falls, the DON stated, She was a two person assist for transfers and that is all I see. The DON stated they felt Resident #43's cushion in her wheelchair was the cause of her fall. She stated the resident brought the cushion from home and was admitted with it. The DON was asked who evaluated the residents for proper positioning in their wheelchairs. She said occupational therapy (OT) usually did that. She said a consult request was made to OT upon the resident's admission on 06/25/14, and again on 07/01/14. The DON acknowledged the OT evaluation did not occur until 07/11/14, six (6) days after the resident's fall with injury. When asked why it took OT so long to evaluate the resident, she replied, They don't actually work here and only come in about once every two (2) weeks. When the OT screened the resident, on 07/11/14, she noted the resident leaned forward in her wheelchair with two (2) degrees of kyphosis (curving of the spine). This would have been information the facility should have known, prior to the fall, particularly with the resident's long torso and use of a cushion in the wheelchair. The OT also noted the use of a personal alarm would be beneficial due to the fact the resident leaned forward in her wheelchair. This intervention for a personal alarm was put into place only after the resident sustained [REDACTED]. Prior to 07/05/14, the facility had already identified the resident at high risk for falls; however, no interventions were developed in an effort to prevent falls. During the interview at 10:15 a.m. on 07/22/14, the DON was asked why no interventions were put into place for Resident #43 when she was assessed upon admission at high risk for falls. The DON replied, Not everyone who is at high risk for falls needs interventions. The DON agreed the facility should have put fall interventions into place prior to the 07/05/14 incident. She agreed the facility's knowledge of a fall assessment at the time of admission and the resident's prior history of falls made it necessary for the facility to put interventions in place to try to prevent future falls and injuries associated with falls. She confirmed the facility had not put those interventions in place prior to the fall on 07/05/14. | 2017-07-01 |