cms_UT: 15
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 688 | D | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, 1 of 41 sample residents did not receive appropriate range of motion services and experienced a decline in range of motion. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 9:45 AM, an observation was made of resident 17. Resident 17 was observed laying in a tilt and space wheelchair, and had contractures to the left upper area of his body. On 2/20/19, resident 17's care plans were reviewed. Resident 17's care plan related to his physical mobility, dated 9/25/17 and revised 1/5/18, documented the following information: a. Focus: (Resident 17) has limited physical mobility r/t (related to) Contracture to L wrist (left), hand, shoulder, hips, knees, and right ankle . b. Goal: Will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date . c. Interventions: MOBILITY: Is totally dependent on staff for locomotion . MOBILITY: Uses Tilt & (and) Space w/c (wheelchair) for locomotion . Monitor/document/report to MD (Medical Director) PRN (as needed) s/sx (signs or symptoms) of immobility: contracture forming or worsening, thrombus formation, skin-breakdown, fall related injury . Provide gentle range of motion as tolerated with daily care . On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was not sure what the restorative therapy staff did for resident 17's contractures. On 2/21/19 at 8:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not know what kind of range of motion services resident 17 received. On 2/21/19 at 8:54 AM, a follow up interview was conducted with RN 1. RN 1 stated she spoke with the Director of Nursing (DON), and resident 17 received gentle range of motion with cares as tolerated in accordance with his care plan. RN 1 further stated she did not know where the range of motion sessions were documented. On 2/21/19 at 9:17 AM, an interview was conducted with the Restorative Aide (RA). The RA stated resident 17 was not participating in the restorative program at present, and she did know when resident 17 last received restorative program services. The RA further stated she did not know where the range of motion sessions were documented. In addition, the RA stated that the therapy staff typically reviewed residents and referred them to the restorative program. On 2/21/19 at 9:21 AM, an interview was conducted with RN 2. RN 2 stated she performed active and passive range of motion exercises with resident 17, but he was not participating in the restorative program. RN 2 further stated there was no documentation of the exercises performed with resident 17. On 2/21/19 at 9:54 AM, an interview was conducted with the Occupational Therapist (OT). The OT stated a contracture screen was performed for resident 17 the week prior and it was noted that he had less range of motion in his wrist. The OT further stated therapy services were determined based on screenings that were conducted a couple times per year, and residents were discharged from therapy services to the restorative program. In addition, the OT stated she did not know when resident 17 had last received therapy services. On 2/21/19 at 10:02 AM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated she also coordinated the restorative program, and all restorative sessions were documented in the electronic medical record as Restorative Nursing notes. The MDS Coordinator further stated she did not know when resident 17 last participated in the restorative program. On 2/21/19, resident 17's Restorative Nursing notes were reviewed. The notes documented the following information: 9/26/17 . Reviewed in RNA (restorative nursing assistance) Meeting: D/C (discharge) RNA PROM (passive range of motion) program. Nursing to provide PROM through pain-free available range w/ (with) cares. (Note: This note was the sole Restorative Nursing note documented in resident 17's medical record.) On 2/21/19 at 10:02 AM, an interview was conducted with the Director of Therapy Rehabilitation (DOR). The DOR stated contracture and range of motion screenings were conducted on a quarterly basis, and resident 17 was receiving therapy services at present related to a little bit of change in his right wrist. The DOR further stated the therapy department trained restorative nursing aides to address residents' specific needs. On 2/21/19 at 10:40 AM, a follow up interview was conducted with the DOR. The DOR stated resident 17 received physical therapy services in (MONTH) (YEAR), and there was no decline in resident 17's range of motion noted at that time. The DOR further stated resident 17 was not referred to the restorative program following physical therapy services, but staff were trained on the floor in accordance with resident 17's needs. On 2/21/19 at 11:51 AM, an interview was conducted with the DON. The DON stated resident 17 did not receive restorative program services, but staff were trained on the floor to perform exercises with him as part of daily cares. The DON further stated any range of motion services were not documented aside from resident 17's care plan and associated kardex. | 2020-09-01 |