| 5 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2018-03-05 |
658 |
D |
0 |
1 |
6C1411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to note/validate a medication order for 1 Resident in a sample size of 43 (Resident identifier is #180.) and failed to ensure proper assessments were performed before moving residents after they sustained falls. (Resident identifiers are: #152 and #186.) Findings include: Potter, [NAME] [NAME], and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 16 Nursing Assessment, page 243. Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough and accurate documentation of facts is necessary when recording client data . If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Resident #186 This Surveyor requested an Accident /Incident Report and an Investigation Report. Review of an Event Report, written by Staff O, LPN (Licensed Practical Nurse), and provided by Facility Staff for an Event that occurred on 2/25/18 at 0100 hours revealed the following: While standing in the hallway heard a bump heard a resident yelling for help, found resident laying between the beds, on her R (right) side (Resident) stated unsure all (he/she) know (sic) that (he/she) was asleep. ask (sic) resident if (he/she) hit (his/her) head, (stated no) resident assist to bed X3 (times three person assist), while in bed began a head to toe assessment no apparent bruising or open areas noticed at this time, Neuro checks performed as protocol per facility (sic). There was no Investigation Report provided. Review of this residents Progress Notes for 2/25/18 written at 3:49 a.m. reveals at approximately 1:00 a.m.this date, this resident was status [REDACTED]. Assessment: nose bleeding, no sign of open injuries, residents BP (blood pressure) as follows 69/41 (BP) 98 (TEMPERATURE) 70 (HEART RATE) 18 (RESPIRATION RATE) 96% RA (room air)(PULSE OXIMETRY LEVEL) 72/45 97.6 18 100% RA, c/o (complaint of) pain both knees. Background: Resident is paralyzed from the hips down, c/o severe pain frequently (sic). On interview, 3/2/18 at approximately 2:10 p.m. Staff C, RN DON (Director of Nurses) stated that Resident #186 raised the bed to a higher position on his/her own. While this resident is paralyzed from the waist down he/she is quite capable of moving himself/herself around in bed and in using the bed control. Because this resident spends a fair amount of time in her bed he/she is on an air mattress to decrease the chance of developing pressure areas. During this interview Staff C stated that there was no Investigation Report and no report to the State Agency because the Facility did not feel there was any mystery as to how Resident #186 had been able to fall out of bed. Resident #152. Record review on 3/05/18 10:16 of the Nurse Note dated 2/22/18 for Resident #152 revealed This nurse informed by supervisor that resident had an un-witnessed fall w/o injury. Resident found in PT (physical therapy) performing exercises w/ staff, stated he had 0 pain, was assessed for injury by PT and supervisor. Denied hitting his head will continue to monitor. No documented evidence of an assessment could be found for Resident #152 un-witnessed fall on 2/22/18. Review on 3/5/18 of incident report dated 2/21/18 for Resident #152 revealed the following, Slipped from chair to floor, in siting position, while attempting to transfer to bed denied hitting head . Assessed by PT and supervisor, no injury noted, vitals taken neuros initiated . Transferring w/out calling for assistance. Interview on 3/5/18 at approximately 12:30 p.m. with Staff [NAME] (Registered .Nurse) revealed that after review of the medical record and nurse notes, Staff [NAME] confirmed that there was no documented evidence of an assessment done by a nurse or a PT following the fall for Resident #152 on 2/22/18. Resident #180 During review of the use of medications in the insulin and anti-coagulant investigative category, an incidental finding of a non-transcribed [MEDICATION NAME] order was identified. Written on 2/20/18 the order reads [MEDICATION NAME] 50 mg Per Oral at bedtime as needed for [MEDICAL CONDITION] signed by Physician Assistant Certified. Order had no indication that it had been transcribed. Review of MAR (Medication Administration Record) for the month of (MONTH) was conducted. There is no entry on the MAR for [MEDICATION NAME] nor any indication that the resident received any doses. Interview with Staff F Registered Nurse (RN) validated the above findings. |
2020-09-01 |