cms_UT: 14
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 684 | D | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 41 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident who had a tube feeding was not positioned appropriately to receive the feeding per the plan of care and one resident who had pressure ulcers did not have her heels floated per the plan of care. Resident identifiers: 9 and 57. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 10:01 AM, an observation was made of resident 9 as she was lying in bed. Resident 9's bed was observed to be at approximately a 20 degree angle. Resident 9 was observed to have slid down in bed, lying flat with her chin resting on her chest. Resident 9's tube feeding was observed to be running. The care plan dated 2/4/19 for resident 9 revealed that resident 9 had a care area of (Resident 9) requires tube feeding r/t (related to) coma. The goal for resident 9 included Will remain free of side effects or complications related to tube feeding through review date. Feeding tube insertions site will be free of s/sx (signs and symptoms) of infection through the review date. Will maintain adequate nutritional and hydration status aeb (as evidenced by) weight stable, no s/sx of malnutrition or dehydration through review date. The interventions for resident 9 included HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed Elevate HOB at least 30-45 degrees at all times during feeding On 2/21/19 at 8:32 AM, an observation was made of resident 9 as she was lying in bed. Resident 9 was observed to be lying flat. Resident 9's tube feeding was observed to be running. On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she was unaware of any special positioning needs for resident 9. On 2/21/19 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that resident 9 should be positioned at 45 degrees, she cannot be flat, she could aspirate. RN 5 stated that the Licensed Practical Nurse (LPN) was just in the room and had just completed the dressing change for resident 9 and should have repositioned her back to 45 degrees. On 2/21/19 at 8:51 AM, an interview was conducted with the facility Director of Nursing (DON) and the facility Corporate Resource Nurse (CRN). The facility DON stated that resident 9 should be at least 30 degrees, not flat. The CRN stated that she will do education right now. 2. Resident 57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 8:41 AM, an observation was made of resident 57's wound care to the pressure ulcer on the top of resident 57's right foot. A foam pad was observed to be under resident 57's knees and calves. An observation was made of resident 57's bilateral heels to be resting on the mattress. physician's orders [REDACTED]. A care plan dated 12/24/18 revealed that resident 57 had a care area of (Resident 57) had pressure ulcer or potential for pressure ulcer development r/t unstageable pressure ulcer right heel and right dorsum foot, impaired mobility, incontinence, hx (history) [MEDICAL CONDITION] [MEDICAL CONDITION]. The goal for resident 57 included Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions for resident 57 included Administer treatments as ordered and monitor for effectiveness Float heels. Follow facility policies/protocols for the prevention/treatment of [REDACTED].>On 2/20/19 at 8:41 AM, an interview was conducted with RN 3. RN 3 stated that obviously we have to talk with the CNAs again as the foam was not placed where it needed to be and you saw her heels on the mattress. RN 3 stated that resident 57 was very compromised and that her heels needed to be floated to prevent the unstageable pressure ulcer that had recently healed, from opening up again. | 2020-09-01 |