cms_UT: 5
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 689 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 2 of 30 sampled residents that the facility did not ensure that the resident's environment remains as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring and care planned interventions were not implemented. Additionally, another resident had sustained [MEDICAL CONDITION] smoking a cigarette. Resident identifiers 64 and 66. Findings include: 1. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/09/18 at 2:15 PM, an observation was made of the resident's room. A fall mat was observed next to bed and the bed was in the lowest position. Resident 64 was observed laying on her left lateral side facing the wall. On 1/10/18 at 11:25 AM, an observation was made of resident 64's room. Resident 64 was not located in her room and this surveyor was unable to locate resident 64 anywhere on the locked unit. On 1/10/18 at 11:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 64 propelled herself around the unit in her wheelchair. RN 1 stated she might have gone to an appointment. When asked who would inform him of her departure from the unit, RN 1 stated transportation would let him know. An observation was then made of RN 1 and Certified Nurse Assistant (CNA) 5 conducting a room to room search of the locked unit to locate resident 64. An observation was then made of RN 1 calling the transportation staff to inquire about resident 64's location. Activities Staff (AS) 1 located resident 64 in room [ROOM NUMBER] on the floor. Resident 64 was observed to be located in front of her wheelchair on the floor laying on her left side with her left cheek resting on the ground. RN 1 was observed to assess resident 64 by performing range of motion (ROM) flexion/extension exercise of resident 64's right lower extremity from the knee joint down. Resident 64 was observed to be non-verbal at this time and eyes were open. An observation was made of RN 1 and CNA 3 assisting resident 64 into a sitting position and then transferring resident 64 into a wheelchair. RN 1 was then observed to assess ROM flexion/extension of bilateral lower and upper extremities, pupil response testing, and then squeeze resident 64's hips. An observation was made of resident 64's posture in the chair as forward leaning and resident 64 was unable to hold herself up independently. RN 1 was observed to hold resident 64 in place in wheelchair during the transfer back to her room. Resident 64's wheelchair was observed not to have a pressure alarm on it. Resident 64 was transferred back to bed with a 2 person assist by RN 1 and CNA 3 by a pivot transfer method. Resident 64 was observed to be unable to bear weight on her left lower extremity and the knee was bent with the leg drawn upward. CNA 3 stated that resident 64 can normally stand with assistance for incontinence brief changes and that her current inability to stand was a change from her baseline. Resident 64's footwear was observed to be socks with no shoes, no slip socks not worn. RN 1 noted to exit the room leaving CNA 3 alone to provide cares. On 1/10/18 at 11:47 AM, an observation was made of the Medical Doctor (MD) assessing resident 64 while lying in bed on the left lateral side. The MD stated that when resident 64 was in pain she was able to vocalize it by crying out, and that resident 64 had a history of [REDACTED]. The MD assessed resident 64 and stated, The resident is guarding her left side and grimaced in pain when left hip was touched and I don't like that she is this quiet. CNA 3 and the MD exited resident 64's room. Resident 64's bed was elevated to hip level with the left side against the wall. No staff were present in the room for approximately 2-3 minutes. On 1/10/18 at 11:55 AM, an observation was made of CNA 3 positioning resident 64 in bed to provide incontinence care. While positioning resident 64 on her back the resident was observed to yell owe multiple times. Resident 64 was observed to resist laying fully supine but attempted to reposition multiple times to the left lateral side. An observation was made of CNA 3 rolling resident 64 to her right lateral side. Resident 64 was agitated and repeatedly stated owe during the position change. Upon completion of the incontinence care CNA 3 was observed to clip the call light to resident 64's sheets next to her head. CNA 3 stated that resident 64 was unable to use the call light to call for help. The bed was placed in the lowest position and the floor mat was observed next to the bed. RN 1 returned to resident 64's room and stated that the MD had ordered an X-ray of resident 64's left hip and left lower extremity. On 1/10/18 resident 64's medical records was reviewed. Review of the incident reports for falls revealed the following: a. On 11/22/17, resident 64 was found on the floor in another resident's room. A small abrasion was noted to the resident's nose. Assessment indicated that resident 64 had a [MEDICAL CONDITION] and it contributed to the fall from her wheelchair. Resident 64 continued to have two more [MEDICAL CONDITION] and Emergency Medical Services (EMS) was called to transport the resident to the hospital. b. On 12/21/17, resident 64 sustained an unwitnessed fall from her wheelchair when the chair became lodged in the door frame to the bathroom. Immediate actions taken was to assess for injuries and neurological checks were started. c. On 1/7/18, resident 64 sustained an unwitnessed fall from her wheelchair and was found on the floor in her room. Immediate actions taken was to assess for injuries and neurological checks were started. Review of the care plan revealed a focus area of at risk for falls related to weakness, cognitive impairment, MS, [MEDICAL CONDITION] disorder. The following interventions was noted on the care plan: a. On 7/23/17 an intervention of Be sure the call light is within reach, family request to keep call light out of reach-Resident does not remember to use call light d/t (due to) impaired cognition-Staff to anticipate resident needs was initiated. b. On 11/22/17 status [REDACTED]. c. On 12/15/17 an intervention of Uses chair/bed electronic alarm. Ensure the device is in place as needed was initiated. d. On 12/21/17 status [REDACTED]. e. On 1/10/18 status [REDACTED]. Review of progress notes revealed a therapy note on 1/10/18 stating, This therapist assessed wheelchair cushion for positioning and comfort identification of need for additional pressure relief to coccyx area and potential need for increased anterior support for proper pelvic positioning, Vicair vector cushion modified with removal of air cells from posterior chambers and added air cells to anterior chambers for increased pressure offloading of coccyx and increased support under distal thighs for pelvic stability. No other documentation could be found to indicate that the wheelchair cushion had been assessed prior to this date. On 1/14/18 the following progress note was added, Late Entry: Note Text: Upon review of re-admission note on 1/5/18, this nurse contacted (name of spouse) regarding his statement that he has found (resident 64) with the call light around her neck. (spouse): I walked into (resident 64's) room on 12/30/17 and she was laying in bed and had her call light wrapped around her neck. I took it off her and I went and told the nurse. The nurse came in and looked at (resident 64) and she was fine. I know she grabs at everything so I don't want her to accidentally hurt herself. I am not concerned that she is trying to harm herself. Notified MD, DON (Director of Nursing), Administrator, SW (Social Work). Advised (spouse's name) that call light will be removed from her immediate reach. Removed call light near resident bed. Resident does not use call light due to cognition. Staff will continue to anticipate needs and monitor frequently. Intervention: SW evaluated resident. Call light was removed from resident immediate reach. Staff was educated regarding reporting incidences in a timely matter. Review of the X-ray report for the left tibia/fibula and left femur on 1/10/18 revealed an impression of no bony abnormalities noted. On 1/11/18 at 7:55 AM an observation was made of resident 64 up in the wheelchair propelling herself down hallway, tab alarm present. Resident 64 was observed to be wearing the same socks as yesterday s/p fall, not no slip socks and no shoes was present. On 1/11/18 at at 8:50 AM an interview was conducted with the DON. The DON stated that resident 64 was currently not wearing non skid socks. This surveyor informed the DON that the resident had the same socks on as yesterday status [REDACTED]. On 1/11/18 at 2:25 PM a repeat interview was conducted with the DON. The DON stated that resident 64 did not have her chair alarm present during the fall on 1/10/18 and that it was removed because the resident likes to lift herself up purposely to hear the alarm sound. The DON was aware that the intervention was still care planned. No further information was provided. On 1/16/18 at 8:22 AM an interview was conducted with the DON. The DON stated that the resident's care plan still states chair alarm as they are effective and needed with her [MEDICAL CONDITION] disorder to alert staff. The DON further stated that she is in the process of working with staff to improve their assessment skills and she in-serviced staff over the weekend on pressure alarm placement and utilizing the Kardex to check the plan of care for residents. 2. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 3:25 PM, an observation was made of resident 66. Resident 66 was observed to reside in the Secured Unit (SNU). Resident 66 was observed to be walking through the hall with black sweat pants. Resident 66's sweat pants hand small holes on the right thigh and knee area. Resident 66's medical record was reviewed on 1/11/18. A care plan dated 6/14/17 and updated on 12/19/17 revealed, (Resident 66) has potential for injury r/t(related to) Smoking, history of non-compliance with smoking policy. The goals developed were, Will have no injuries related to smoking and Will be compliant with smoking protocols and individual smoking plan until next review. Interventions developed on 6/14/17 were, Observe smoking while in designated area and supervision while smoking. Resident 66's progress notes revealed the following entries: a. 6/9/17 at 8:07 PM, Weekly note/skin check: Resident is alert and oriented x 2-3 (person, place and time). Able to verbalize needs and concerns to staff.Burns noted on R (right) finger from smoking. b. 6/13/17 at 8:22 PM, .Burns noted on R finger from smoking. c. 7/12/17 at 2:38 PM, Saw resident walking down the hall towards outside. I gave another resident a pain pill. I went outside to see if she was really outside. I caught the resident outside picking up cigarette butts by the cigarette holder. I told the resident she cannot go outside without a staff member. I asked her what she was doing and she replied looking for a cigarette to smoke. I educated her on scheduled smoke breaks and that she cannot be outside at this time since it is not a smoke break. I returned the resident to her room to try to get more sleep. d. 7/16/17 at 11:56 PM, This evening around 2345 (11:45 PM) a staff member observed the resident outside with a lighter. The nurse and aide approached the resident and asked her about the lighter and the resident denied having one in her room or outside. Resident will continue to be monitored when she goes outside, DON (Director of Nursing) will be notified also. e. 7/19/17 1:51 PM, Skin/Wound Note Note Text: 1. R 3rd finger superior, burn: 0.7cm (centimeter) L (length) x 1.3cmW (width) x 0cmD (diameter). 2. R 3rd finger distal, burn: 0.4cmL x 0.4cmW x 0cmD. 4. R 4th finger, burn: 0.4cmL x 0.4cmW x 0cmD.Resident educated on dressing care. f. 7/19/17 at 11:27 PM, Tonight another resident told me that they saw (resident 66) with a lighter and that's why she has been trying to get butts out of the holder. When I asked (resident 66) if she had a lighter she told me she did not. I asked her if I could look around her room and she said I could. After looking around residents room I found a pink lighter. Resident said it was '(name removed)'. I explained to her that she is not allowed to have lighters in her room. I told her I would hold on to in the nurses cart with her name on it. Resident understands she is not allowed to have lighters in her room and knows that the nurse has her lighter. g. 7/21/17 at 1:07 PM, IDT reviewed an incident that occurred on 7/19. Resident noted to [MEDICAL CONDITION] her right 3rd AND 4TH FINGERS. Resident stated that while she is smoking the cherry falls off [MEDICAL CONDITION] finger. However resident is on supervised smoking and this has not been witnessed. Resident has been witnessed collecting cigarette butts and a lighter was found in her room. It appears resident has been smoking the cigarette butts while unattended.a friend was notified as well as NP (Nurse Practitioner). Resident educated on the risk of smoking the butts and the risk of burning herself, she allowed staff to search her room where the lighter was found and she agreed to keep it at the nurses station.[MEDICAL CONDITION] treated per MD orders. h. 7/24/17 at 4:00 AM, Nurse found resident outside in employee parking smoking a cigarette. When asked what resident was doing she stated she was smoking. Nurse asked where resident got the cigarette and resident said she had it in her purse. Nurse and CNA asked resident to give the remaining cigarettes to the nurse and resident stated she didn't have any more. Resident showed nurse and CNA that her purse was empty of cigarettes. i. 8/2/17 at 6:14 PM, R 3rd finger distal, burn: 1.3cmL x 0.8cmW x 0.1cmD. Wound bed red moist granulation. Peri-wound macerated from bandage being wet, no drainage noted. No odor present. Resident denies pain r/t wound. Dressing applied per order. Resident educated on dressing care. j. 8/3/17 at 6:02 PM, SS (Social Services) contacted Weber County Ombudsman regarding resident and smoking policy. Ombudsman stated that he spoke with resident and resident expressed understanding of smoking policy and smoking safely. No other concerns noted at this time. k. 8/8/17 at 11:15 PM, Reddened area to left knee. No blistering noted and resident denies any pain or discomfort to area. Educated resident on not getting hot beverages. Instead I gave her the tea packets from the med room. No signs or symptoms of infection. Earlier the aids informed me that she was outside smoking at 1630 (4:30 PM) before scheduled smoke break and unsupervised. When the aid asked where she got the cigarette from she replied 'a stranger'. Educated the resident on the smoking policy. Will continue to monitor her. l. 8/17/17 at 1:35 PM, Res was noted to be outside digging through the cigarette butt container and getting the cigarette butts out and eating them. Staff educated resident on smoking policy and not eating butts. Res communicated understanding. Res placed remaining butts that were in her hand back into the container. Res was also found to have a lighter this AM, res re-directed and gave the lighter to the staff. m. 12/6/17 at 6:35 PM, Blisters found on resident's left knee smaller than the size of a dime all together. There is a hole in her sweats from a cigarette burn. Res was wearing apron while smoking during shift. Blisters are still closed and res states no pain. n. 12/7/17 at 9:05 AM, IDT Late Entry: Note Text: Resident reviewed in IDT following incident in which resident was noted to have blisters on her leg with burn marks through her pants. Staff educated that resident must be supervised at all times during smoke breaks and that staff must ensure proper placement of smoking apron to prevent injury. Resident 66's smoking evaluation revealed the following: a. 6/14/17, Resident attends supervised smoking sessions. She is unsafe to smoke independently. b. 8/7/17, Resident has cigarette holder that employee puts cigarette in the holder for resident. Employee is lighting cigarette for resident. Resident correctly and safely used cigarette holder. c. 8/31/17, Resident has been on a floor where she could smoke when ever she wanted unsupervised but recently has moved to the lock down memory unit-resident falls asleep while smoking and drops cigarette ashes on her clothes can not unsupervised - discussed with resident the safety issues and the need to be supervised while smoking and the smoke times the floor goes out. On 1/6/18 at 12:10 PM, an interview was conducted with the DON. The DON stated that the unit manager that looked into the burn incident on 12/6/17. The DON stated that the unit manager did not work at the facility. The DON stated that she did not know how resident 66 [MEDICAL CONDITION] she was supervised during smoking. On 1/11/18 at 2:19 PM, a follow up interview was conducted with the DON. The DON stated that she thought resident 66's smoking apron moved to the side and was burned by the ash. The DON stated that staff were to watch her and make sure the cigarette did not burn down to resident 66's fingers. The DON further stated that resident 66 was supplied with an extender for her cigarette. The DON further stated that all residents on the D hall were supervised during smoking. The DON stated that staff monitored the blisters to see what happened and CNA's should have watched her closer when smoking to prevent the apron from sliding. The DON stated that resident 66 resided on the C hall and was found smoking unsupervised. The DON stated that resident 66 was moved to the D hall for increased supervision. On 1/11/18 at 3:12 PM, a follow up interview was conducted with the DON. The DON stated that there were no investigation into [MEDICAL CONDITION] 66 sustained on 6/9/17, 7/19/17, 8/2/17 and 12/6/17. | 2020-09-01 |