cms_AL: 12
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2018-06-07 | 700 | E | 0 | 1 | FTJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #3 also confirmed RI #12 was not able to use the side rails. When asked if she could provide evidence the resident was assessed to determine the risk of entrapment, EI #3 said she could provide a fall risk assessment, but it did not address entrapment, only confusion and falls. When asked if residents should be assessed to determine if side rails were appropriate for them, EI #3 said the facility only used one size of side rail, and it was not individualized for each resident's needs. EI #5, the Interim Director of Nursing, was asked to explain the facility's process for determining whether a resident requires the use of siderails on 6/07/18 3:52 PM . EI #5 said she came to the facility in mid (MONTH) of (YEAR) and had determined the facility was not using an assessment tool for siderails. She also said she was working on a policy, but neither the policy or the assessment for siderails had been implemented yet. When asked how the size of siderail a resident requires should be determined, EI #5 said therapy should be involved in that decision, but that had not yet been implemented. During a follow-up interview with EI #5 on 6/07/18 at 4:55 PM, the Interim Director of Nursing said RI #12 should have two top siderails up, but did not know what size. EI #5 further stated RI #12 had not been assessed for the risk of entrapment; nor did the facility have informed consent for the use of the side rails. On 6/07/18 at 5:18 PM, EI #5 stated the facility did not currently have a policy addressing siderail use. She further said none of the 28 residents identified by the facility as utilizing siderails had informed consent for the use of their side rails. | 2020-09-01 |