cms_AZ: 44
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 44 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 689 | D | 1 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, facility documentation and staff interviews, the facility failed to provide adequate supervision for one resident (#268) with known aggressive behaviors. Findings include: -Resident #268 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for resident #268 dated (MONTH) 20, (YEAR), revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also documented that the resident had physical behavioral symptoms against others that significantly interfered with the resident's care and put others at significant risk for injury. An activities note dated (MONTH) 21, (YEAR) stated the resident became agitated during bingo and began throwing bingo cards in the direction of other residents. An activities note dated (MONTH) 22, (YEAR) stated that resident #268 hit a staff member on the arm. Review of a care plan dated (MONTH) 23, (YEAR) revealed the resident exhibited behaviors of physical aggression such as hitting and kicking, during routine care. Interventions included to intervene before agitation escalates, guide resident away from the source of distress, provide one-on-one interaction, staff to re-approach the resident later or have a different staff member attempt to assist the resident, and if the resident becomes aggressive, staff should ensure her safety and give her time to calm down. A nursing note dated (MONTH) 25, (YEAR) included that resident #268 hit three staff members in the stomach and tried to kick them. Review of the behavior monitoring record for (MONTH) and (MONTH) (YEAR) revealed 4 episodes of resident #268 yelling out and 5 episodes of the resident striking out at staff. A physician's orders [REDACTED]. A nursing note dated (MONTH) 24, (YEAR) at 1:08 a.m., stated the resident was awake, roaming the halls and refusing care. The resident's pants were half on/half off and the resident was removing her clothes in the middle of the hall. A nursing note dated (MONTH) 18, (YEAR) included the resident was verbally aggressive with staff in a common area where other residents were present. The note also stated the resident tried to ram her wheelchair in the direction of another resident. Review of the resident's care plans revealed no evidence that they were updated to address the resident's aggressive behaviors toward other residents. Further review of the clinical record revealed there was no documentation that the resident was provided increased supervision, despite documentation of aggressive behaviors toward residents. A nursing note dated (MONTH) 25, (YEAR) revealed that resident #268 was extremely agitated, was screaming loudly, and swinging out, when a female resident was walking by, the resident hit her in the chest/abdomen area. The note also included that resident #268 was immediately removed from the area, staff continued to keep her away from other residents, and she began to wander in the hallway screaming loudly and speaking inaudible words. Review of the facility's investigative report regarding the incident on (MONTH) 25, (YEAR), revealed resident #268 was seen striking another resident as the resident walked by her. Per the clinical record, the resident was discharged to the hospital on (MONTH) 28, (YEAR) for continued/worsening altered mental status. An interview was conducted on (MONTH) 8, 2019 at 9:32 a.m., with a Licensed Practical Nurse (LPN/staff #52). She stated she witnessed the event between the two residents, and she was the author of the nursing note that documented the event. She stated that another resident was walking by as resident #268 was very agitated. She stated the arm of resident #268 was flailing when it struck the other resident. She stated neither resident was injured during the event. | 2020-09-01 |