cms_UT: 45
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 45 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 689 | G | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and medical record review, it was determined for 3 of 43 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident was transferred via use of a sliding board by a CNA (Certified Nursing Assistant) who had received no training for the transfer. In addition, observations were made of a laundry chute that was unlocked and unattended, two chemicals were found in an unlocked and unattended housekeeping closet and multiple oxygen tanks were found to be stored near an exit doorway as well as empty and full oxygen tanks being stored in the same closet. Resident identifiers: 7, 56 and 37. Findings include: HARM 1. 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. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. 1/24/18 at 17:56 (5:56 PM), (Recorded as Late Entry on 1/26/18 at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. 1/25/18 at 5:50 AM, Alert and oriented x (times) 3. Res reports ongoing UTI (urinary tract infection) symptoms. F/U (follow up) UA (urinalysis) at lab at this time. Midline remains in place at RUE (right upper extremity) flush without difficulty. One person ext. (extensive) ass (assistance) with brief changes. No s/s (signs/symptoms) injuries r/t (related to) recent fall. No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. 1/25/18 at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on 01/24/18, no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) 111/66 and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. 1/26/18 at 5:38 AM, IV ABX (antibiotic) infusion and flushes without difficulty. Afebrile, alert and oriented x 2 this shift. C/O pain at Rt (right) leg r/t recent fall. Reports about a 5/10 because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. 1/26/18 at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) 105/59 and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. g. 1/26/18 at 19:15 (7:15 PM), Received report from day nurse. Portable x-ray in rout (sic) for x-ray of Rt. hip and LOE (lower extremity). Res (Resident) is alert and oriented x 2. Res reports no pain at this time unless moved. Res informed of coming procedure. h. 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 she goes to. Res 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. i. 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. j. 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 . An X-Ray report dated 1/26/18 at 19:27 (7:27 PM) revealed that Bones: Two views were obtained with limited positioning. There is a nearly [MEDICATION NAME] oriented [MEDICAL CONDITION] right tibial metaphysis without any obvious displacement on this AP (anterior-posterior) radiograph. There is also a [MEDICATION NAME] oriented adjacent acute [MEDICAL CONDITION] right fibula but this appears to be associated with an area of old healed fracture as well. There is an old healed [MEDICAL CONDITION] fibular diaphysis .Impression: Acute nondisplaced fractures of the proximal right tibia and fibula although radiographic evaluation is limited . A facility Event Report dated 1/24/18 at 14:44 (2:44 PM) revealed that the investigation of the fall was completed on 1/25/18 and closed on 1/31/18. The Event Report revealed the following: Fall Summary: Intercepted fall (resident eased to the floor). Location of Fall: Resident Room. Shift when Occurred: Day. Activity during or just prior to fall: Transfer assisted by staff. Was fall witnessed: Yes By Whom: (CNA 1). Does resident exhibit or complain of pain related to the fall? If so, describe location. Yes, location right lower leg. On a scale of 0-10, how does resident rate intensity of pain if able or indicate based on observation. 5-6: Moderate Pain Note any injury to the head, extremities, or trunk. No injury noted. Does the resident exhibit or complain of the following: Weakness. Range of Motion: ROM X 4 without pain/limitations. Positioning of extremities: Rotation/Deformity/Shortening of Right Lower Extremity. Level of Consciousness: Alert wakefulness - Perceives the environment clearly and responds appropriately to stimuli . Speech: Clear - Distinct, intelligible words . Last toileted: 1400 (2:00 PM). Resident continence status at time of fall: Wet . Did resident complain of, experience or be observed with any of the following prior to/at time of fall: Lost strength/appeared to get weak . Were restraints/devices in use at the time of the fall: Yes - slide board . IDT Notes: Resident status prior to event (assessment): During transfer using sliding board, patient slid on the floor. No injury noted at that time. Risk Factors: MS ([MEDICAL CONDITION]); [MEDICAL CONDITIONS]; [MEDICAL CONDITION]; history of venous [MEDICAL CONDITION] and embollsm (sic); TIA ([MEDICAL CONDITION]); CKD ([MEDICAL CONDITION]); urine retention; [MEDICAL CONDITIONS]; OSA ([MEDICAL CONDITION]); [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION];[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease); hx (history) of recurrent UTIs (urinary tract infections). Use of sliding board per order. Preventive measures prior to even: sliding board use as per order. Care plan risk factors and interventions: The following areas reviewed: progress notes; orders; care plans . Resident/Staff Education: Root Cause: CNA removed sliding board thinking patient is sitting at the edge of the bed New Interventions Implemented: RP (unknown) MD informed; ROM and skin check assessment; CNA to have 1:1 with PT (physical therapy)/OT (occupational therapy) to review transfers using sliding beard (sic), care plan update. 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.) A New Employee Orientation Checklist dated 1/15/18 for CNA 1 revealed that CNA 1 had been oriented regarding using gait belts for transferring residents safely and the proper way to use mechanical lifts such as a hoyer lift and sit to stand lift. No documentation could be located in the employee file to show that CNA 1 had been trained to safely use a sliding board for transfers. On 4/26/18, a written statement by CNA 1 was provided by the facility DON. The written statement revealed, Nurse needed (Resident 37) into bed, I was notified she was a 1 person transfer on board. We fixed her shirt for a transfer into bed, she wanted to rest. I fixed her wheelchair to (sic) close to her bed and place (sic) transfer board under her leg and on her bed. Transferred (sic) with barrer (sic) weight 100 %. She tried to help me tranfer (sic) her but got to (sic) weak, she was already on the board between her wheelchair and bed, we tried (sic) to transfer again from same position but slid forward onto my weight and slid off board. Called for help while she was barring her weight on me and no one came. No one came to help, after the fall, she slowly slid on to floor. The Inservice Training/Seminar Report regarding Slide Board Transfer Review that accompanied CNA 1's written statement was dated 1/28/18, four days after resident 37's fall from the sliding board transfer. On 4/26/18, a form that was not dated was provided by the TD for safety measures for resident 37 revealed the following: a. Precautions: falls, skin integrity b. Assistive Devices: FWW (Front Wheeled Walker), slide board, power w/c (wheelchair). c. Transfers: Ext (extensive) A (assistance) x 1 person using FWW or slide board. d. Comments: Sometimes (Resident 37) is having a weaker day than normal. She will let you know when she wants to use the slide board, instead of the FWW. On 4/26/18 at 1:00 PM, an interview was conducted with the TD. The TD stated that the undated form was some training that was provided to CNA 1 after resident 37's fall. No documentation could be located in the medical record to show that CNA 1 had been trained regarding safe practices when using a sliding board for transfers. On 4/26/18 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she heard a loud thud the day of resident 37's fall and that CNA 1 started yelling. LPN 1 stated that she went right into the room and assessed resident 37 for injuries. LPN 1 stated that the sliding board had not been placed correctly onto the bed and subsequently had become loose from the bed. LPN 1 stated that resident 37 was not on the bed far enough and started to fall and that CNA 1 lowered her to the floor. LPN 1 stated that her assessment for injuries consisted of placing her hand on resident 37's hip and then bending her right leg up and down at the knee, to see if she could feel any popping out of the hip. LPN 1 stated that she was able to know if there was a problem with her hip if there was popping out. LPN 1 stated that resident 37 was picked up off of the floor to a standing position and assisted back to bed. LPN 1 stated that the CNAs were aware of the transfer needs by resident 37 because they were in a binder at the nursing station. (NOTE: The transfer needs available in the binder were the current needs for resident 37.) LPN 1 stated that the previous paperwork for resident 37's needs had been shredded. On 4/26/18 at 2:00 PM, an interview was conducted with the Therapy Director (TD). The TD stated that therapy would change out the paperwork in the CNA binders at the nursing stations and that the paperwork was there to inform the CNA staff of the transfer needs for the residents. The TD stated that he no longer had a copy of the assistance that was required for resident 37 prior to resident 37's fall on 1/24/18. The TD provided physical therapy notes dated 12/20/18 which revealed a short term goal for resident 37 that Pt will perform sliding board transfer bed w/c (wheelchair) safely w (with)/CNAs and therapy. The target date for the goal was 1/16/18. The TD stated that there had not been any training provided to the CNA staff regarding sliding board transfers but that a lot of the CNAs in the facility have been here for [AGE] years and know how to do sliding board transfers. On 4/26/18 at 2:35 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 confirmed that there was paperwork that detailed the resident's needs for transfers and that the had been kept in a binder at each nursing station. RN 1 stated that all the paperwork was updated as the resident's needs changed and confirmed that the previous paperwork for resident 37's transfer needs in (MONTH) (YEAR) had been shredded. RN 1 stated that because the needs of the residents change so often, that the old paperwork was no longer needed. On 4/26/18 at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that she obtained her information from documentation from the CNA staff as well as the nursing staff to complete the MDS section G for Functional Status. The facility MDS Coordinator stated that the slide board transfer training had not been provided to the CNA staff and that the CNA staff should never have been attempting to transfer resident 37 with the slide board. The facility MDS Coordinator stated that the slide board transfer training had only been provided to the RNA (Restorative Nursing Assistant) staff. The facility MDS Coordinator confirmed that the staff member that had attempted to transfer resident 37 just prior to the fall on 1/24/18 was a CNA and that she should never have attempted the transfer with resident 37. On 4/26/18 at 4:45 PM, an interview was conducted with Resident 37. Resident 37 stated that she remembered the fall on 1/24/18. Resident 37 stated that the sliding board had not been properly placed on the bed and that when it became loose, CNA 1 pulled the sliding board out from the bed and she fell on her knee. Resident 37 stated that she had been unable to stand on her leg when the nursing staff helped her off the floor because she had severe pain in her right leg after the fall. Potential for Harm 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's medical record was reviewed. A History and Physical (H&P) dated 12/13/18 at 1:04 PM revealed that resident 56 was admitted with altered mental status and hepatic [MEDICAL CONDITION] which was treated with [MEDICATION NAME]. Nursing progress notes revealed the following episodes of confusion and altered mental status: a) 12/19/17 at 12:47 AM, resident had critically high serum ammonia level of 140. b) 12/20/17 at 9:17 AM, staff reported that res (resident) refused breakfast this am, nurse went in to check Res and he reports that he didn't refuse breakfast .when nurse returned to the room .res yelled what after she called his name, he states that nurse was bothering him .nurse tried to recheck his BP (blood pressure) after first check was 85/50 .and he refused and started saying to 'go away.' c) 12/20/17 at 10:15 AM, (resident 56) is more confused and lethargic today d) 12/20/17 at 10:23 AM, (resident 56) couldn't recall talking to MD before nurse returned to the room. e) 12/24/17 at 1:07 PM, Resident was found standing next to the toilet .staring at the wall. facial twitching noted. Resident responded inappropriately to every other question with WHAT DO YOU WANT?! slight bilateral tremors noted BUE (bilateral upper extremities) .Nurse assisted resident to his bed requiring 1 person extensive assist f) 12/24/17 at 6:27 PM, Resident was found urinating on heating vents .when asked what he was doing residents only response was WHAT! Nurse attempted to move patient away from the area, resident began swinging his arms .Nurse assisted resident back to bed .requiring 1 person extensive assist .Due to residents cognition needs were anticipated, attempted to change his soiled clothes the resident swung his arm hitting CNA on her ribs .Resident alert and oriented to self. when asked why he hit the CNA his only response was WHAT! pupils were dilated, exhibited facial ticks, BUE involuntary tremors, Unable to follow simple commands . g) 12/28/17 at 10:14 AM, (resident) requires supervision for transfers, bed mobility, toileting and meals. h) 1/1/18 at 11:01 PM, Resident is acting exceedingly confused tonight .(resident) was repeatedly trying to get out one of the rear doors, entering the wrong door codes several times in a row, and unable to enter the appropriate code even when another resident related the proper code to him. Resident was unable to verbalize why he wanted to go outside .Resident was repeating back bits and pieces of Nurse's speech. Displayed short bursts of angry behavior, followed by laughter .Also noted rocks and mud in water, in a cup in his bathroom. Asked resident why he had that, and he stated that it was so that he could 'check up on the staff.' i) 1/1/18 at 11:14 PM, Ammonia drawn with some difficulty. Nurse and CNA escorted Lab Tech to Resident's room, given the concern about violent behavior. Resident began yelling at lab tech, but then agreed to allow draw if brought a cup of juice. Nurse quickly obtained orange juice per his request, and resident agreed to allow draw. Juice was handed to CNA Resident stated The juice is TOO CLOSE!!! and CNA held the juice farther back. Then he stated, I can't see it now! and orange juice was brought closer. At which point, (resident) grabbed juice from CNA's hand, nearly spilling it, before quickly drinking it down. CNA instructed to perform frequent checks on Residents. Nurse plans to do so as well. j) 1/2/18 at 8:50 AM, (resident) responds to questions with what .visible tremors in right hand noted. Res does not answers (sic) to questions appropriately, hen (sic) .he move his hand toward nurse as he attempted to hit her . k) 1/2/18 at 1:27 PM, Res continues to have generized (sic) tremors, not following commands, responds to voice but only answers what to questions. Res was found standing in front of the sink, holding on to top of mirror. two person extensive assist needed to get him back to his bed, when nurse attempted to give his med, he continued to move his head from left to right and then lay back down . l) 1/3/18 at 1:01 AM, Resident continues to display confused behavior .confused about time .Resident ambulated down the hall and defecated on the carpet .Now grunting and grimacing as if he is in pain, but states he does not want any medications. This is unusual behavior for this resident .CNA and Nurse making frequent and regular checks upon resident. m) 1/3/18 at 9:36 AM, Res is alert and awake to name only. when ask (sic) about situation, place or time, res stays quiet and keeps eating .visible tremors noted to bil (bilateral) hands, unsteady gait when ambulating .res has been seen getting out of bed on his own at time, staff immediately in room to help d/t fall risk. Res required two person extensive assist for transfers . n) 1/6/18 at 12:20 AM, monitoring continues r/t recent episodes of tremors/lethargy/change in mental status . o) 2/1/18 at 2:40 AM, (resident) stated he had fallen in his room .(he) stated he was getting up from chair and went down onto his bottom. asked how he went down, pt stated that his feet went out from under him and he landed on his bottom . p) 2/1/18 at 9:55 AM, (resident) appears lethargic, oriented to name only, will answer silvers when asked for the year .visible hand tremors noted .res requires supervision for transfers, bed mobility and toileting .mental status has changed from baseline . q) 2/2/18 an IDT note investigating the fall on 2/1 at 2:40 AM revealed (the resident) states his legs were weak and did not realize it until he stood up frequent visual check by LNs and CNAs due to patient intermittent confusion . r) 2/3/18 at 3:07 AM, entered room to find pt standing at door to BR (bathroom or bedroom) in a puddle of urine, noted confusion w/ pt, pt is responsive verbal/tactile stimuli, doesn't answer questions . s) 2/3/18 at 6:28 AM, (resident) continued to not answer questions . t) 2/3/18 at 6:46 PM, .patient was sitting on toilet he has eyes closed, he will answer questions when shaken but gets irritated when you shake him to answer questions . u) 2/26/18 at 9:46 AM, pt with twitching movement to bil (bilateral) hands and legs, responds to voice but unable to follow commands properly v) 2/26/18 at 6:08 PM, (resident) requires extensive assist from staff for ADL's . w) 2/27/18 at 8:34 AM, (resident) reports that yesterday 'I was out of it' x) 3/14/18 at 10:15 AM, pt appears oriented with slow mentation . y) 3/14/18 at 7:00 PM, this nurse noted that pt appeared to (sic) drowsy/sedated z) 3/14/18 at 8:56 PM, pt appears to continue w/ drowsiness/sedated behavior .told pt we were concerned and that he appeared to be behaving differently . aa) 3/18/18 at 10:31 AM, pt with slight tremors, standing in front of toilet, does note (sic) follow commands, just states to leave him alone . bb) 3/19/18 at 1:02 AM, Resident .with variable sense of time, but confusion and forgetfulness . cc) 3/23/18 at 5:22 AM, res on floor .when asked what happened, res replied what. When asked res's (sic) name, res replied what. res continued to reply what to all questions asked dd) 3/23/18 at 5:56 AM, Resident continues to appear to be drowsy/lethargic, wont grasp hands when prompted or push w/ feet when prompted . ee) 3/23/18 at 8:00 AM, Resident remained lethargic in bed .resident is incontinent of bladder, currently wearing brief Resident is unable to respond to simple questions. His only response to any question is 'What' . ff) 3/23/18 at 12:00 PM, Resident is still lethargic and unable to appropriately respond to simple questions. resident remains incontinent of bladder .needs are anticipated by staff due to cognition . gg) 3/23/18 at 7:01 PM, (resident) .does not elaborate .nor does he make eye contact Resident is exhausted and has stayed in bed the whole shift .Resident requires 1 person extensive assist with transfers, toileting, bed mobility and hygiene. hh) 3/23/18 at 10:08 PM, res appears to continue w/ drowsiness. res has been up and ambulating w/ assist to BR and back to bed. res is .providing some verbal response to questions like 'what', 'yeah' . ii) 3/30/18 at 8:16 PM, resident does not remember and is unaware of his lethargic state .Resident stated he needed to go out to buy a phone, make a stop to (Grocery Store) to buy some snacks. Resident was gone for 5 hours. leaving at 1130 and returning at 5:15 PM. Resident left again around 5:45 stated he was going to (Name of Restaurant) to get a malt shake and he has not returned . 3/30/18 at 9:13 PM, res returned to facility at approx (approximately) 2030 (8:30 PM) w/ groceries in hand . jj) 3/29/18 at 3:31 PM, Resident is lethargic and unable to follow simple instructions, When asked how he feels resident will only reply 'WHAT?!' Resident unable to swallow pills and refused to eat due to his condition. Involuntary bilateral tremors noted to BUE, Resident is B&B incontinent . kk) 4/7/18 at 12:38 PM, Pt had good sleep from 1100 am till now . ll) 4/7/18 at 4:56 PM, Pt slept most afternoon (sic) . mm) 4/7/18 at 6:00 PM, Pt was very lethargic .aid (sic) down in roommate's bed around 1700 PM. 3 staff tried to persuade Pt to go back to his own bed. Pt agreed to go back to his own bed, sat up, but could not stand up by self, refused to be touched, then refused to go back to his own bed. Pt sat in bed with eyes closed, high fall risk. Nearly half an hours (sic), staffs (sic) held Pt's arms, Pt stepped to his bed nn) 4/8/18 at 11:13 AM, Resident .had episode of lethargic (sic) and hospice came in and assessed resident. oo) 4/13/18 at 8:52 AM, pt is laying perpendicular to the bed, attempting to stand it (sic) up on his own, answers 'what' to every question, visible tremors, unable to take meds at this time d/t risk of aspiration. pt was assisted up and lay in bed properly . pp) 4/13/18 at 1:00 PM, .pt continues be (sic) lethargic, tremors, unsteady gait when ambulates. pt required two person assist to go back to bed after attempting to get up to go to the bathroom . qq) 4/19/18 at 2:28 PM, Pt has been lethargic today Pt urinated on the floor and attempted to redirect patient .Hospice states he has been having more episodes similar to this lately . rr) 4/20/18 at 8:46 AM, pt resting in bed .unable to follow commands .does not answer questions accordingly meds were held this am ss) 4/23/18 at 10:59 AM, He was comatose last Thursday and Friday . tt) 4/24/18 at 8:54 AM, Res. noted to have ST (slight tremor) to posterior left hand .Res. reports he obtained it when he passed out. Res. dose (sic) not recall when he 'passed out.' . A review of resident 56's Medication Administration Record [REDACTED]. The resident did not take medications on the following dates: a) 2/3 Not administered: due to condition. Comment: not able to wake up enough to swallow meds. b) 3/23 Not administered: due to condition. Comment: Resident lethargic unable to take meds. Notified hospice., c) 3/24 Not administered: Refused. Comment: Pt very sleepy. Hospice notified., d) 3/29 Not Administered: Due to condition. Comment: Lethargic and unable to swallow., e) 4/1 Not Administered: Due to condition. f) 4/13 Not administered: Other. Comment: Pt unable to swallow. g) 4/19, Not administered: Due to condition. Comment: resident is very drowsy; meds held. h) 4/20 Not administered: Other. Comment: clinical decision. On 4/25/18, a log of when resident 56 left the facility was obtained. The following entries were identified on the log: a) Sign out: 12/14/17 at 11:00 AM. Return: 2:20 PM b) Sign out: 12/18/17 at 2:27 PM. No return time recorded c) Sign out: 12/18/17 at 2:45 PM. Return: 4:10 PM d) Sign out: 12/30/17 at 10:35 AM. Return: 1:00 PM e) Sign out: 12/31/17 at 11:55 AM. Return: 2:15 PM f) Sign out: 1/5/18 at 12:55 PM. Return: 7:50 PM g) Sign out: 1/6/18 at 12:30 PM. Return: 4:15 PM h) Sign out: 1/8/18 at 4:10 PM. Return: 7:30 PM i) Sign out: 1/10/18 at 11:15 AM. No return time recorded j) Sign out: 1/10/18 at 1:45 PM. Return: 7:40 PM k) Sign out: 1/11/18 at 11:10 AM. Return: 6:40 PM l) Sign out: 1/12/18 at 1:15 PM. Return: 3:30 PM m) Sign out: 1/14/18 at 12:15 PM. Return: 5:55 PM n) Sign out: 1/16/18 at 12:50 PM. No return time recorded o) Sign out: 1/18/18 at 7:50 PM. No return time recorded p) Sign out: 1/19/18 at 3:20 PM. No return time recorded q) Sign out: 1/24/18 at 5:00 PM. No return time recorded r) Sign out: 1/28/18 at 12:30 PM. Return: 2:15 PM s) Sign out: 1/31/18 with no sign out or return time recorded t) Sign out: 2/11/18 at 6:15 PM. Return: 8:50 PM u) Sign out: 2/13/18 at 2:45 PM. Return: 8:20 PM v) Sign out: 3/1/18 with no sign out or return time recorded w) Sign out: 3/30/18 with no sign out or return time recorded x) Sign out: 3/30/18 with no sign out or return time recorded y) Sign out: 4/3/18 at 9:00 AM. No return time recorded z) Sign out: 4/5/18 at 11:45 AM. No return time recorded aa) Sign out: 4/5/18 at 7:40 PM. No return time recorded bb) Sign out: 4/9/18 at 9:30 AM. No return time recorded cc) Sign out: 4/11/18 at 1:40 PM. Return: 2:14 PM dd) Sign out: 4/16/18 with no sign out or return time recorded ee) Sign out: 4/22/18 at 2:30 PM. No return time recorded ff) Sign out: 4/23/18 at 2:00 PM. No return time recorded While reviewing the progress notes, it was revealed that the resident had left the facility without documenting when he left or returned on the sign out log. The following occurrences were identified in the progress notes: a) 3/21/18 at 7:25 PM, Resident left LOA (leave of absence) this morning stated he was going to (Church Property). last Pain medication was given around 8 am. resident left facility at 1045. Resident returned at 1530, stated he had a lot of fun. resident laughed and joked and stated he was in a lot of pain 10/10. administered prn pain medication granting positive results to the resident . b) 3/27/18 at 6:00 PM, pt arrived to facility after being gone a couple hours. pt stated to nurse that he fell when he was in a department store. described i | 2020-09-01 |