cms_UT: 43
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 |
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43 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 657 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined, for 1 of 43 sample residents, that the facility did not review and revise the comprehensive care plan. Specifically, one resident's care plan was not revised to reflect that a resident who had a tibia/fibula fracture, was placed as a non weight bearing status. Resident identifier: 37. Findings include: Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity). (Physician 1) called T.O. (telephone order) send res to E.R. (emergency room ) of choice for F/U. Daughter called, no answer, message left. Res is alert and oriented x 2. Res informed of report and trans (transport) to hospital. Res cant (sic) remember which hosp (hospital) she goes to. Res (resident) reports little pain at this time. PRN pain medication given r/t transport and repositioning. Daughter just returned call and stated (Name of Hospital) is fine. b. 1/27/18 at 00:15 (12:15 AM), 2330 (11:30 PM) (Name of Ambulance) here to trans res to (Name of Hospital) for X-rays to Rt lower leg. All HS (hour of sleep) and prn pain medication provided prior to trans. c. 1/27/18 at 3:14 AM, 0300 (3:00 AM) Res returned from hospital per (Name of Ambulance). Fx confirmed at RLE. F/U appt (appointment) to be made with (Physician 2) MD. Phone (phone withdrawn) ASAP (as soon as possible). Paperwork from Hospital states this Fx is non-operative. Res is to be non-wt (weight) bearing and leg should be protected during transfers. Res is alert and oriented. Res does not want a PRN pain pill. She states she just wants to go to sleep. ABX infusing at this time. Flushed without difficulty . The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 37 required an extensive 2 person assistance with transfers. The ADL Care Plan dated 7/11/16 for resident 37, revealed the following: ADL Functional/Rehabilitation Potential Impaired mobility, generalized weakness and chronic pain with ROM impairments to BLE (bilateral lower extremities). Requires extensive assistance x 1-2+ staff for transfers, bed mobility. The Goal on the ADL Care Plan revealed that (Resident 37) will receive the assistance she needs to complete all ADL's and preferred routines Q (every) shift and as needed or requested. The Approaches included, Provide extensive assist x 1-2 for bed mobility, transfers, toileting, dressing, bathing and locomotion on/off unit (NOTE: The MDS Assessment and the care plan documented a discrepancy between a two person extensive assistance by facility staff and 1-2+ person extensive assistance by facility staff.) No documentation could be located in the medical record to show that facility staff revised the comprehensive care plan so that facility staff would know that resident 37 was a non weight bearing status. On 4/26/18 at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated she was the only person to do the MDS Assessment for the entire facility and that she was overwhelmed. The MDS Coordinator stated that she was having a hard time completing the MDS Assessment and then updating the care plans to reflect the resident current status. The MDS Coordinator stated that the care plan should have been updated to reflect resident 37's non weight bearing status. | 2020-09-01 |