| 8623 |
WAR MEMORIAL HOSP, D/P |
5.1e+151 |
1 HEALTHY WAY |
BERKELEY SPRINGS |
WV |
25411 |
2012-12-07 |
280 |
D |
0 |
1 |
L97I11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to review, assess the effectiveness of, and revise the care plan when two (2) of fourteen (14) sampled residents had changes in their healthcare needs. Resident identifiers: #1 and #12. Facility census 16. Findings include: a) Resident #1 A review of the record revealed that Resident #1 had been admitted on [DATE]. The resident was observed at 4:00 p.m. on 12/03/12, sitting in a tilted back geri chair in her room. She moves her body and limbs with jerky movements and calls out occasionally. She was being fed a pureed diet by a nursing assistant. During an interview with Employee #9 (nurse aide) at 3:50 p.m. on 12/04/12, she stated the resident stayed up a large part of the day and was in the tilted geri-chair because she would try to reach her feet to take off her socks and staff were afraid she would fall out of the chair. The aide stated that this had been the daily practice for the four (4) months she had worked at the facility. During an interview with Employee #1 (Registered Nurse) at 6:45 a.m. on 12/05/12, the nurse stated they had found when the chair was tilted back, the resident could not fall out as she had in the past. The nurse did not remember how long they had been doing this, but at least for several months. She stated the resident exhibited these repetitive movements daily. A review of the current care plan dated 05/07/09 - 01/03/13 revealed the following interventions regarding the geri-chair: During periods of agitated behavior, tray table to be up when up in geri chair ., While resident is up in geri-chair staff will check resident at least every hour and will assist and provide ADLs, fluids, toileting, and meals. When sitting up in chair, resident's feet will be supported by foot rest if chair is not reclined., and Chair alarm when up in chair (when tray table not in use) to notify staff that resident needs assistance. There is nothing in the care plan about using the tilt position when the resident is in the geri-chair, although it was observed in use daily. The annual MDS (minimum data set) section P0100G is marked for a restraint, described Chair Prevents Rising and the CAA (care area assessment)indicated that it would be addressed in the care plan. During an interview with the Director of Nursing (DON) at 8:45 a.m. on 12/06/12, these findings were discussed. At 9:30 a.m. during a follow-up interview with the DON and Social Worker they agreed, after reviewing the record, the use of the tilt-chair had not been addressed in the resident's care plan. b) Resident #12 A review of the medical record revealed Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her annual screening by Rehabilitation Services on 08/29/12, indicated that her left hand was contracted and suggested continuing the use of a splint on this hand, although the resident removed it at times. The active physician's orders [REDACTED]. This order was added on 09/30/11. The care plan was not revised to include the presence of a contraction with a measurable goal. The care plan continues to include Arm sling to left arm while up and Adjustable resting splint to (L) hand/wrist 20 - 24 hours per day to manage (L) digits and wrist in neutral position. Employee #1 (Registered Nurse) stated at 6:30 a.m. on 12/05/12, that the sling or the splint were no longer used because the resident would not leave them on. The resident was observed daily during the survey and a sling or splint was at not time in place. At 9:50 a.m. on 12/06/12, Employee #19 (nurse) was asked to locate the sling and splint in the resident's room. After searching, she did locate a clean sling and sheepskin hand wrap in a storage cabinet in the room, but she and the DON, who was also present, agreed the staff were not attempting to use them on a regular basis. During an interview, shortly after, the DON acknowledged that the care plan had not been revised to accurately describe the care of the resident. |
2016-05-01 |