cms_AK: 30
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 30 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 689 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure; 1) a malfunctioning bed was recognized and removed from service in a timely manner for 1 (#17) out of 14 sampled residents, and 2) staff were trained on the proper use of the bed. Specifically, the resident was lying in a malfunctioning bed for an unknown length of time. This failed practice created a potential risk for harm and/or injury from 1) potential improper inflation leading to increased risk of pressure ulcers and 2) risk of entrapment from potentially improper inflation of the mattress and impingement of bed rails. Findings: Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 8/19/19 at 4:00 pm, revealed the Resident lying on an air mattress in his/her [NAME]-rom (a brand of facility) bed, with both upper 1/2 bed rails in the up position. The monitor at the foot of the bed was blinking with a service required message, and a yellow light was illuminated below the monitor. An observation on 08/20/19 at 1:49 pm, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor read please call [NAME]-rom [PHONE NUMBER] service code 7,and a yellow light was illuminated below the monitor. An observation on 08/21/19 at 2:47 pm, revealed the Resident's bed was functioning properly. There was no error message and a green light was illuminated. A dressing change to the Resident's head was attempted by Licensed Nurse (LN) #1. LN #1 lowered the head of the Resident's bed prior to the procedure. Once the head of the bed was lowered, the service required message reappeared on the monitor, and the yellow light was illuminated. When the head of the bed was raised back up, the air mattress began working properly. During an interview on 8/21/19 at 2:49 pm, LN #1 stated he/she was not aware of any problems with the Resident's air mattress. An observation on 8/22/19 at 8:01 am, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor of resident's bed revealed a service required message, and a yellow light was illuminated. During an interview on 8/22/19 at 10:00 am, LN #4 stated he/she was not aware of any problems with Resident #17's bed, or any service codes. LN #4 further stated that the [NAME]-rom bed would have had an audible alarm if it was not functioning properly. During an interview on 8/22/19 at 11:00 am, the Biomed Staff (BMS) stated he/she was not aware of any bed malfunctions, and no service issues were reported to him/her. During an interview on 8/22/19 at 11:52 am, the BMS stated Resident #17's bed was taken out of service and the Resident was moved onto a new bed. The malfunctioning bed was placed in an empty room. The BMS stated he/she contacted [NAME]-rom and was told error message 7 indicated a malfunction of the mother board. The BMS turned the damaged bed on, and audible alarms started beeping with error codes 3 and 4 illuminating on the monitor. The BMS stated that was indicative of a problem right away. The BMS stated if there was a problem with the bed, an audible alarm would sound and a yellow light would illuminate. When asked how staff would know this information, the BMS stated staff could have referred to the manual attached to the foot of each bed. An observation on 8/22/19 at 11:55 am, revealed no manual attached to the foot of the Resident's malfunctioning bed. The BMS stated there should have been a manual provided with each bed. The BMS further stated that he/she does not train staff regarding the [NAME]-rom beds. During an interview on 8/23/19 at 11:06 am, the Administrator (AD) stated that the BMS attended the Quality Improvement/Performance Improvement (QAPI) committee meetings but the focus was on the equipment safety and not staff training. The AD further stated that staff were trained on equipment during new hire training and during annual mandatory training fairs. When asked what the process was for addressing malfunctioning equipment, the AD stated that the staff would check the sticker on the piece of equipment, alert the charge nurse, and place a phone call for a work order. The AD stated that the facility had been trying to order two new air beds due to an issues with malfunctioning beds. Document review of the most recent Facility Assessment, dated (MONTH) & (MONTH) 2019, revealed no plan for staff training on new or standard medical equipment such as air mattresses or other resident specific equipment. During an interview on 8/23/19 at 12:48 pm, LN #2 and LN #3 stated that they had not received training on the new beds, and the facility had not yet offered that training to staff. LN #2 further stated that if he/she was familiar with new equipment, he/she would have educated Certified Nursing Assistants (CNAs) individually. LN #2 and LN #3 were both unaware of a process for facility wide training for all staff when new equipment was introduced. During an interview on 8/23/19 at 1:32 pm, CNA #1 stated that sometimes the facility provided training on new equipment but other times the staff would have ask the boss. When asked how they would know if the equipment was malfunctioning, CNA #1 stated, common sense. A review of Multidisciplinary Problems (Active)' not dated, revealed Problem: Alteration in skin integrity . with start date 5/10/16, with Goal: Resident will be free of any skin breakdown or pressure ulcers . An intervention listed included Verify and document use of pressure reduction mattress for wound prevention. A review of a physician progress notes [REDACTED]. A review of Multidisciplinary Problems (Active)' not dated, revealed Problem: Risk for injury r/t (related to) assist device (s) on bed ., with start date 5/10/16, with Goal: Resident will be free from injury associated with assist device (s) on bed. | 2020-09-01 |