cms_GU: 56
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 56 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2013-09-20 | 157 | E | 0 | 1 | JK1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the primary attending physician regarding a change in medical condition for Resident 5 and 8 related to reports of the residents wanting to hurt/harm themselves. 1. Resident #5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident 'might want to hurt or kill' themselves. During the tour, the resident was not observed to be in their assigned resident room. An interview was done with LN 3 on (MONTH) 19 at approximately 5:10 PM. The staff person stated that she was not the assigned staff for the resident that shift, and that near the end of the shift (3 PM - 11 PM) she took a phone call from the friend of the resident on (MONTH) 13, 2013. Staff 3 said the caller sounded worried and like they were about to cry, and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad. LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. Review of the nursing notes on (MONTH) 13, 2013 timed at 11:20PM read, The (friend) of this patient called and said Can you go see (resident) in her room, she might slice her wrist. CNA and other nurse went to patient's room. Patient still awake, CNA found a kitchen knife and removed the knife in her room. Patient was up in wheelchair and went upstairs. I went upstairs and give knife to security and told him to watch this patient. On (MONTH) 14, 2013 at 10PM, an entry in the nursing notes read, Called Dr. (attending) informed him about the patients mental state last night. Was informed of suicidal ideation and acting out last night. Incident report was filed. Dr. (attending) ordering to have mental consult and monitor patient and on Level 1 suicide protocol until seen by mental health personnel . . An interview with LN 2 on (MONTH) 19, 2013 at 5:10PM was done related to the resident's change in condition/emotionsl status that took place on (MONTH) 13, 2013. There were several disconnects that should not have happened after the incident took place. The residents' physician should have been contacted the night the incident happened rather than the next day. 2. Resident 8 was admitted to the facility on (MONTH) 10, 2013 with a [DIAGNOSES REDACTED]. During an interview with the resident while completing the initial tour on (MONTH) 18, 2013, he was returning from physical therapy, and stated that he was 'sore, but okay.' Review of the residents medical record indicated that the SW 2 had documented an interview with the resident on (MONTH) 18, 2013 at 3:19PM that Resident stated that he had been feeling sad due to his present medical condition and severe pain to both legs. He noted that he has thoughts of hurting himself when he experiences severe pain .This worker discussed counseling at GBHWC (Guam Behavioral Health and Wellness Clinic) .And he agreed. Review of the Medication Administration Record [REDACTED]. Further record review on (MONTH) 20, 2013 revealed that the resident was transferred to and seen by a mental health professional on (MONTH) 19, 2013. Nursing notes revealed that the patient returned from GBHWC at 6PM. There was no documentation from GBHWC regarding the evaluation. The only documentation from GBHWC was a one-page document titled Discharge Instructions that said to Return to GBHWC if you feel like harming yourself or others, and to Call the crises line if you feel you need to talk to somebody . Review of the SNU Resident Appointment Communication Form revealed that it had been completed by Guam Memorial Hospital Skilled Nursing Unit, but the part for the treating physician/clinician to whom the resident was transferred to be seen for evaluation was blank. Review of nursing notes did not include any reference to or assessments related to suicide ideation or risks factors for suicide prior to being evaluated at GBHWC. An interview was done with SW 2 on (MONTH) 20, 2013 at approximately 11:57AM regarding her interaction with the resident and the notes she documented in the medical record on (MONTH) 18, 2013. SW 2 stated that the resident reported to her thoughts of suicide. I was interviewing the resident, and he told me of his thoughts to hurt and harm himself. That's when I made sure the referral was made for him to be seen by GBHWC. She added, I didn't tell the charge nurse about the suicide ideation, only his depression. I should have told her so they would have been watching him closely, and not just made the note in his record. There was no documentation in the medical record that the resident's physician was notified about the encounter the resident had with facility staff on Septamber 18, 2013 regarding his desire to hurt/harm himself until (MONTH) 20, 2013 at 12:40PM | 2018-07-01 |