| 91 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2019-05-15 |
657 |
D |
0 |
1 |
0E0S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, record reviews, observations, and interviews the facility failed to ensure the care plan was updated to include all interventions to prevent falls and/or minimize injuries from falls for one (1) of 24 Residents, Resident #51, reviewed for safety, supervision and/or falls. Findings include: Review of an undated facility policy, titled Care Plans - Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .4. Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly . Review of an undated At risk for falls care plan, revealed interventions of: Bolsters on bed; Encourage resident to wear appropriate footwear when ambulating or mobilizing in wheelchair; Fall risk eval on admit, quarterly and prn (as necessary); PT (Physical Therapy) evaluate and treat as ordered and prn; Review information on past fall to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes, tilt wheelchair to prevent forward leaning. The care plan lacked the interventions for a low bed and mats on the floor at her bedside, that were currently being implemented by facility staff. An observation of Resident #51 on 05/12/19 at 8:42 AM, revealed the resident laying in a low bed, with a mat on the floor, visiting with a family member. The family member stated she had asked the staff to place a mat on the floor because she did not want Resident #51 to be hurt from falling out of bed. Review of Resident #51's undated Face Sheet found in the electronic medical record, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Assessment (MDS) with an assessment reference date of 03/28/19, revealed Resident #51 had long and short-term memory problems, and was moderately impaired with decision making. The resident required extensive assist of two (2) staff for bed mobility, transfer, toilet use, and required extensive one (1) staff assist for dressing, eating, and personal hygiene. The MDS also documented Resident #51 had a history of [REDACTED]. Review of the CAA (Care Area Assessment) dated 03/28/19, revealed Resident #51 had difficulty maintaining sitting balance and impaired balance during transitions. The CAA indicated the resident had a potential for falls. During an interview on 5/14/19 at 3:00 PM, the MDS Coordinator confirmed the interventions of the low bed and mat to floor should have been added to the fall care plan for Resident #51. During an interview on 05/15/19 at 1:45 PM, the DON confirmed the care pan had not been updated to include the interventions for a fall mat and the low bed. She confirmed the care plan was not accurate, and it should include all interventions to prevent falls or reduce injuries from falls. |
2020-09-01 |