cms_OR: 21
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 21 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 580 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to notify a resident's physician of a decline in mobility and a new bruise for 1 of 5 sampled residents (#1) reviewed for change in condition and injury of unknown origin. This placed residents at risk for delayed care. Findings include: Resident 1 was admitted to the facility in (YEAR) after surgical repair of a [MEDICAL CONDITION]. The resident's Admission Nursing Data Base dated 9/20/18 indicated the resident was alert and oriented to person, place and time. The resident was assessed to have bruises to the arms and was not assessed to have functional impairment to the legs. The Physical Therapy Treatment encounter notes indicated PT services started on 9/21/18. The resident had pain and the pain limited the resident's functional activities. The resident required close supervision when the resident walked to ensure safety was maintained. The resident was able to walk 300 feet on a level surface. The 9/22/18 notes indicate the resident did not have pain, walked in the hall for 300 feet on two occasions, used the four wheeled walker and required stand by assistance. On 9/24/18 the resident walked 40 feet with a walker and hands on assistance and staff were required to provide cues for the majority of the task. On 9/25/18 the resident reported no pain and walked 25 feet with hands on assistance. On 9/26/18 the resident had improved stability with the use of the walker, walked 25 feet and reported right groin pain. On 9/27/18 the resident denied pain and was able to walked 57 feet with minimal assistance. The 9/28/18 note indicated the resident had severe pain, fatigue and strength deficits. The resident was only assisted to transfer and did not walk. On 9/29/18 the resident again reported severe pain to the right hip when the resident attempted to bear weight. The note indicated the pain limited the resident's functional activities and the resident did not make progress. There was no documentation to indicate the resident's physician or nursing staff were notified of the resident's change in ability to walk. On 10/24/18 Staff 6 (Therapy Director) indicated the resident had increased pain and weakness starting on 9/28/18. Staff 6 indicated the nursing staff was responsible to communicate with the physician when there was a change in status. The resident's clinical record did not have documentation to indicate the resident's physician or nurse practitioner was notified of the change in the resident's decreased ability to walk after 9/27/18. The 9/29/18 at 9:13 am nursing Progress Notes indicated the resident was identified to have a new bruise to the right thigh. The note indicated the bruise was light purple and approximately seven cm by eight cm. The note revealed the resident's family was aware of the bruise but the note did not indicate the physician was notified. The 10/1/18 Physical Therapy Treatment Encounter Note indicated the resident was assisted with toileting and the resident was not able to correct the right leg external rotation. The nursing staff was notified and the nurse was to notify the physician. The 10/1/18 Progress Note by Staff 2 (Nurse Practitioner) indicated she was notified in the morning of 10/1/18 the resident had a new bruise to the right posterior thigh. The bruise was first noted on Friday but she was not notified until Monday. The note also indicated the resident had increased pain and therapy reported the resident had difficulty with the movement of the right leg. Staff were instructed to notify the orthopedic surgeon of the changes and an X-ray was ordered. On 10/24/18 Staff 4 (RNCM) indicated the therapy department communicated with nursing on the Daily 24 Hour Report. The therapy department reported concerns including issues related to decreased oxygenation levels or if a resident developed dizziness. Staff 4 indicated the RNCMs review the daily report and if a significant change was identified the physician was notified. Staff 4 stated it was not uncommon for a resident to have fluctuations in the ability to walk after hip surgery. Staff 4 indicated the resident's physician was not notified of the resident's right thigh bruise and decreased ability to walk until Monday 10/1/18. On 10/24/18 at 12:21 pm Staff 2 (Resident 1's Nurse Practitioner) indicated she was not aware the resident had a functional change with therapy, increased pain and the resident's right inner thigh bruise. Staff 2 indicated if she would have been notified of the location of the bruise and change in mobility on 9/28/18 she would have requested an X-ray of the resident's hip a few days earlier. Staff 2 stated the resident's outcome would not have changed but surgical interventions would have been able to be implemented sooner. The 10/9/18 hospital Discharge Summary indicated the resident was found to have a failed hip replacement. The resident was identified to have a pathological fracture (fracture caused by disease not trauma) due to [MEDICAL CONDITION] (bone weakening). | 2020-09-01 |