cms_WY: 3
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-04-11 | 657 | D | 1 | 1 | TYBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, family and staff interview, and policy review, the facility failed to revise the care plan to reflect resident needs for 3 of 37 residents (#63, #71, #108) reviewed. The findings were: 1. Review of the 2/9/19 quarterly MDS assessment and the 3/1/19 significant change MDS assessment showed resident #63 wandered 4 to 6 days of the 7-day look-back period. The following concerns were identified: a. Observation on 4/8/19 at 9:25 AM showed the resident had a WanderGuard (device to alert staff of possible elopement) attached to his/her right ankle. b. Review of a nurse's note dated 3/22/19 revealed the resident was exit seeking and a WanderGuard and been placed. c. Review of the care plan, last revised 2/19/19, failed to show interventions to address the resident's wandering or the use of the WanderGuard. d. Interview on 4/11/19 at 11:18 AM with the DON confirmed the care plan did not address the resident's wandering or the use of the WanderGuard. 2. Review of the 3/5/19 quarterly MDS assessment showed resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Further review showed the resident required the extensive assistance of 2 staff for bed mobility, transfers, and toileting. The following concerns were identified: a. Observation on 4/7/19 at 5:44 PM showed the resident had a bruised area on the right side of his/her face. b. Interview on 4/8/19 at 10:27 AM with the resident's son revealed the resident had fallen twice since admission; the first time the resident sustained [REDACTED]. The son stated the resident was sleeping in the recliner and fell out. c. Review of a nurse progress note dated 4/2/19 showed the resident had been sleeping in the recliner and at 3:45 AM the resident was found on the floor in front of the recliner the resident sustained [REDACTED]. Additional review of the nurse progress note showed the resident was transferred to the hospital on [DATE] at 10 AM and returned during the evening. d. Interview with LPN #1 revealed the resident was kept safe by providing 1:1 care to the resident. e. Interview on 4/11/19 at 9:09 AM with CNA #3 revealed the resident slept in the recliner and the staff reclined the chair back because the resident was unable to. The CNA further stated the resident did not sleep in his/her bed and had not slept in the bed since admission. f. Interview on 4/11/19 at 2:27 PM with HSA #1 revealed when staff tried to lay the resident down in bed s/he immediately tried to crawl out. She stated staff transferred the resident to the recliner, provided a pillow and blanket and s/he fell asleep. She further stated when the resident needed something s/he yelled out. g. Review of the care plan showed 4-2-16 fall from recliner with laceration above right eyebrow .keep pillows on each side in recliner to increase comfort-anticipate and meet needs Interview on 4/10/19 at 10:35 AM with LPN #2 revealed she added the statement to the care plan on the evening of 4/9/19. She further stated staff were educated to add pillows while the resident was in the recliner, due to resident's size and dry elbows. Further review of the care plan failed to show planning related to the resident's preference to sleep in the recliner and attempts to crawl out of bed. h. Review of the Fall Evaluation and Management policy dated 3/18 showed .Reviews and updates the care plan with newly identified interventions as needed . 3. Review of the 3/8/19 admission MDS assessment showed resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 14/15 (cognitively intact). The following concerns were identified: a. Review of a physician communication form dated 3/24/19, from a RN at the facility, showed the resident had bilateral lower extremity [MEDICAL CONDITION] (BLE) and the resident had reported when s/he was at home that his/her legs were wrapped every day. The RN requested an order for [REDACTED]. b. Review of the resident's care plan last revised 3/14/19 showed the resident had a [DIAGNOSES REDACTED]. Further review of the interventions showed no evidence the use of the ACE wraps was addressed. c. Interview on 4/11/19 at 1:45 PM with the MDS coordinator revealed she was unaware of the addition to the resident's treatment plan and verified the care plan had not been revised. | 2020-09-01 |