| 32 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-03-21 |
689 |
G |
1 |
0 |
U1E811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review, the facility failed to reduce multiple falls, one with a pelvis fracture, for 1 (#3); failed to monitor and modify interventions and failed to identify meaningful root causes for falls, for 2 (#s 3 and 11); and failed to ensure Hoyer lifts, used for transfers, were completed with sufficient staffing, for 1 (#5) of 11 sampled residents. Findings include: 1. Review of the facility Fall Report showed resident #11 fell 12 times from 10/25/17 through 3/16/18. On 12/14/17, she fell and fractured her pelvis. a. Review of resident #11's Follow-Up Report for the fall on 10/25/17, showed she fell out of her wheelchair. Her socks were slippery, and she landed on her bottom. The root cause was her non-skid socks were worn out and slippery. The recommendation for the prevention of future falls was for newer socks with a non-skid bottoms. During an observation on 3/20/18 at 10:00 a.m., resident #11 had regular socks on, and not non-skid socks. b. Review of resident #11's Follow-Up Report for the fall on 10/27/17, showed she slipped and fell on her buttocks, as she transferred herself from the wheelchair to the bed. The root cause was Pt. transferring herself said she slipped and fell . The recommendation was to lock wheelchair brakes and keep next to the bed. Automatic wheelchair brake to be installed by maintenance. Review of a second fall on 10/27/17, showed the wheelchair was not locked, and it rolled away and she fell on the floor. The facility failed to implement the locked brakes on the wheelchair. She was not wearing slipper socks. Review of the Maintenance Log, dated 10/30/17, showed Please put back up brakes on wheelchair. c. Review of resident #11's Follow-Up report for the fall on 10/28/17, showed she fell out of her wheelchair. The intervention for future fall prevention was, Dycem placed beneath and on top of her wheelchair cushion. During an observation on 3/20/18 at 10:01 a.m., resident #11's wheelchair did not have dycem on the cushion. It did have a towel. d. Review of resident #11's Follow-Up report for the fall on 10/30/17, showed she was seen slipping to the floor and was holding on to arms of wheelchair. A transfer pole was installed in her room. During an observation on 3/20/18 at 10:05 a.m., resident #11's room do not have a transfer pole. Staff member D stated the therapy department removed it, because it was not safe for the resident. The transfer pole installation and removal were not documented on the Care Plan, or in the Nursing Progress Notes. e. Review of resident #11's Follow-Up report for the fall on 11/18/17, showed she was found sitting on the floor on her bottom. Resident's cushion had slid out of the chair with her and was still under her bottom when she was sitting on the floor. PT to evaluate wheelchair cushion for proper fit and stability. The dycem intervention to prevent slipping was not mentioned in the report. No evidence was provided for the PT evaluation for the cushion. f. Review of resident #11's Follow-Up report for the fall on 12/4/17, showed she was found on the floor, laying on her back. She stated the chair flew out from under me. The investigation did not include whether the wheelchair antilock breaks were in use. The root cause was Resident fell during self-transfer. g. Review of resident #11's Follow-Up report for the fall on 12/14/17, showed the resident stated she was transferring herself to the bathroom. The wheelchair was found in a corner of the room, away from the resident. The report did not specify why the wheelchair was in a corner. The root cause was toileting need. The resident complained of right hip pain, but no injury could be noted. The resident requested to go to the emergency room . Nurse asked the resident if she was certain she felt she needed to go and pointed out that no injury at this time could be found. Resident #11 was sent to the emergency room , and returned to the facility with a [DIAGNOSES REDACTED]. h. Review of resident #11's Fall Detail report for the fall on 1/21/18, showed the resident was found on her knees, next to the bed. She was on a fall mat. The root cause was toileting needs and restlessness. No new interventions were implemented. The need to anticipate resident #11's toileting needs was not addressed in the investigation. i. Review of resident #11's Fall Detail report for the fall on 2/4/18, showed her bed was in the low position, and she rolled out of bed. She hit her head and had a right eye hematoma. No root cause was identified, or new interventions implemented. Supervision was not addressed as an intervention, or lack of, for a root cause for resident #11's 12 falls. j. Review of resident #11's Fall Detail report for the fall on 2/27/18, showed she was barefoot, and found lying on the floor in her room. She stated she was taking herself to the bathroom. No root cause we identified; signs were placed in her room to remind her to call for assistance. During an observation on 3/20/18 at 10:06 a.m., resident #11's bed was not in the low position, and there was not a fall mat in the room. Resident #11 stated she moved the bed up and down, as she needed. During an interview on 3/21/18 at 8:40 a.m., staff member A stated the facility did discuss falls in their quality assurance meeting, and noted the fall rates were higher than the facility wanted. She stated the root causes on the fall reports were not meaningful. 2. Review of resident #3's Observed Fall report, dated 3/15/18, showed CNA called this nurse to resident's room, resident was on the floor sitting in front of her wheelchair with her legs on the EZ lift; sling was off and she was still hanging on to the right handle. CNA hooked her up to the sling for the EZ stand; everything was going OK, then the left sling slipped off and down to the floor. (The resident) landed on her bottom and tweaked her back and head, had a pain level of seven. The action taken was CNA was reinforced to use a 2 person transfer. The report did not include a signature or any other interventions. During an interview on 3/20/18 at 3:30 p.m., resident #3 stated she was hysterical and cried after the fall. My butt slugged the floor hard, and it hurt my sores that were just healing. During an interview on 3/21/18 at 8:50 a.m., staff member F stated she had been the staff member transferring resident #3 the day she fell . She stated she was frazzled that day, and so she did not check the placement of the sling. She stated she still transferred resident #3 by herself, and the resident was OK with that. She stated even with two people transferring the resident the day of the fall, she would still have fallen, but would not have hit the ground so hard. 3. During an interview on 3/19/18 at 3:30 p.m., resident #5 said staff transferred him using a Hoyer lift. Resident #5 said when using the Hoyer lift, only one CNA had been in the room operating the lift. Resident #5 said he did not feel safe when that happened. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident was a total assist of two staff for transfers. During an interview on 3/20/18 at 2:28 p.m., staff member A said the Hoyer lift is to be used by two staff members when transferring a resident. Staff member A said a representative of the lift manufacturer was in the facility two months ago and did training for all the staff on the proper techniques used for the sit to stand and the Hoyer lifts. Staff member A said she did have a CNA come to her recently and tell her she had been using the Hoyer lift by herself to transfer residents. Staff member A said she asked the CNA why she had done that. The CNA said because there was no one to help her. Staff member A said she told the CNA the Hoyer lift required two staff members during a resident transfer, and if she couldn't find another CNA or nurse to help her, she needed to get the DON or anyone from the front office to assist her with the Hoyer lift transfers. |
2020-09-01 |