cms_UT: 60
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 60 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 689 | E | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 4 of 28 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not on supervised smoking, had repeated falls outside while smoking, and did not have documentation that neurological checks were performed after the resident had a fall and hit his head. The same resident had repeated interventions. Another resident's fall was not assessed nor were appropriate interventions put in place. Another resident had an incident with her power wheelchair and an assessment for her safely utilizing the powerchair was not completed until a month later. Another resident had multiple falls with no new interventions. Resident identifiers: 3, 13, 32, and 43. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 3's medical record was reviewed. Resident 3's progress notes revealed the following: a. On 1/1/19 at 10:54 AM, resident 3 was on 72 Hour Event Charting for an unwitnessed fall. The actual event was not documented in the progress notes. The note on 1/1/19, appeared to be the only note charted for that particular fall. b. On 1/2/19 at 1:59 PM, a Fall note was completed which stated Resident found sitting on floor in front of chair. States that he got dizzy and fell . Resident tried getting up without walker. Assessment complete .Freq (frequent) visual checks performed. Resident reminded to use walker when getting up or call for assistance . c. On 1/4/19 at 2:57 PM, an IDT (interdisciplinary team) Event Review was completed. It stated it was for an unwitnessed fall on 12/31/18. It stated: .Resident went outside to smoke .Resident was found outside on ramp, Resident was feeling tired earlier in the day, nurse encouraged resident to stay inside and rest but insisted on going outside. Refused to have nurse or staff present with him. Staff found resident outside on the ramp. Resident stated to nurse that he felt weak and lost his balance and fell when he was walking back inside from smoking and fell on the ramp .Root cause: likely r/t (related to) ambulating with walker outside when not feeling well. New interventions implemented MD (Medical Doctor) and caregiver notified. New orders for STAT (immediately) UA (urinalysis), CBC (complete blood count), and BMP (basic metabolic panel). Lad (sic) results came back MD reviewed and no new orders noted. Neuro checks were started. Education to resident to ask for assistance when feeling tired. PT (physical therapy) post fall assessment. Will continue to monitor and notify MD of any adverse changes. d. On 1/4/19 at 7:30 PM, an IDT Event Review was completed. It stated it was for an unwitnessed fall on 1/2/19. It stated: Residnet (sic) was found on the floor in his room next to chair. Residnet (sic) stated 'I was trying to get up but I got dizzy and passed out. I am okay though.' Neuros started. Full assessment complete .Resident reminded to use walker when getting up or to call for help. Freq visual checks in place .Root cause: resident fell when getting up from chair. New interventions implemented: MD was notified no new orders. PT post fall assessment, neuro checks. On further investigation resident stated he got up without his walker and fell . PT and nursing to continue to educate resident to use walker when ambulating or even just standing up to reposition. Resident stated understanding. Continued education to ask for assistance and use call light when needing assistance. Sign placed in room to remind resident to ambulate with walker e. On 1/19/19 at 10:33 AM, an Event/Alert Charting note was initiated. It stated resident was found outside at side door had fallen and hit head on falling. Small hematoma noted on back of head. grips equal and strong, eyes equal and reactive. Interventions: Reminded to ask for assistance when needed. when (sic) over call light instructions. Resident reaction to interventions: I just want a cigarette . f. On 1/21/19 at 2:32 PM, an IDT event review of fall on 1/19/19 was completed and stated the following: Resident was found outside at the side of the door, he had fallen and hit head on railing. Small hematoma noted on back of head Preventive measures prior to event: frequent monitoring and observation by direct care staff, nursing assessment, call light within reach. Root cause: likely r/t losing balance outside and falling. New interventions implemented: MD and caregiver notified, Neuro checks started, PT post fall, Have resident on assisted smoking due to recent falls outside. Encourage resident to use walker when ambulating. Notify MD of any adverse changes. Continue to monitor hematoma to head . g. On 2/7/19 at 5:26 PM, a nurses note stated the following Pt (patient) was found smoking in his bedroom, sitting in recliner. Reminded pt of smoking policy. 1 extra cigarette removed. Pt denies having a lighter. Will continue to monitor. h. On 3/8/19 at 6:30 PM, an Event/Alert Charting was initiated. It stated: Reported from previous nurse, that around 18:15 (6:15 PM) patient was found on his knees on the floor, next to his chair in room [ROOM NUMBER], patient was alert, responsive to verbal and physical stimuli, cooperative, able to ambulated (sic) with walker, skin intact, no redness, swollen (sic) noted, no pain reported .No c/o (complaints of) pain at this time, when asked patient what happened stated I was sliding off from chair . i. On 4/11/19 at 5:30 AM, a nurses note stated At 5:45 AM patient lying on the floor, looking up, alert, able to follow commands, oriented by name person and place, stated wanted to put the shoes (sic), lost balance and fell , assessment done, small abrasion on nose and forehead, no bleeding, no swollen, no pain reported, vital signs were taken .after 10 minutes went outside to smoke, instruction about safety and fall precaution given, patient v/u (unknown acronym) and will use call light for assistance, Neurocheck started . On 5/22/19 at 1:08 PM, an observation was conducted of resident 3's room. The sign which was to be implemented as an intervention for the fall on 1/2/19 was not observed. Resident 3's neuro reports were reviewed. The facility had documentation of neuro checks in their medical charting system for the following dates: 12/31/18, 1/2/19, 3/8/19 and 4/11/19. Neuro checks for the date of 1/19/19 in which the resident fell outside, hit his head on a railing and obtained a small hematoma was not located. There was file under the date of 1/19/19, however they were a copy of the neuro check for the fall on 3/8/19. A copy of the neuro checks done on 1/19/19 was requested from the facility and was not provided. Resident 3's smoking safety evaluations were reviewed. Resident 3 had a quarterly Smoking Safety Evaluation completed on 2/3/19 which revealed the following: a. Resident demonstrates impaired orientation in one or more of the following areas: Person, Place, Time . b. Resident has a [DIAGNOSES REDACTED]. c. Resident demonstrates one of more of the following cognitive impairments: Poor safety awareness, impaired short-term memory, impulsiveness . d. Resident has a history of unsafe smoking practices . e. Resident demonstrates non-compliance with smoking policy (i.e. smoking in designated areas only, appropriate disposal of cigarettes, etc.) . f. Resident has condition or [DIAGNOSES REDACTED]. At the bottom of the smoking safety evaluation, a section titled Scoring had the following marked for resident 3. 4-6 points (each of the above statements was a point). Resident is unable to smoke independently. Resident requires supervision while smoking. Care Plan required. Review for need of behavioral program. Completion of Risk vs. (versus) Benefits needed. Provide and document education for identified safety needs. Resident 3 had an assessment for his fall risk completed on 2/3/19. This was a quarterly assessment titled Morse Fall Scale. The assessment revealed that resident 3 was identified as a high fall risk. Under section C or Ambulatory Aid resident 3 was identified as one who uses crutches, cane or walker. Under section F titled Mental Status resident 3 was identified as one who overestimates or forgets limits. On 5/22/19 at 11:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she worked in the hall which resident 3 resided once a week. RN 2 stated that if a resident fell , neuro checks would be initiated. RN 2 stated nurses could assess what's going on and let people know what an intervention could be but ultimately interventions came from management. RN 2 stated that the root cause would be identified by the Director of Nursing (DON) and other management members. RN 2 stated that the root cause and intervention comes from our documentation. RN 2 stated that interventions to prevent further falls were communicated down to the nursing staff by the DON or Assistant Director of Nursing (ADON). RN 2 stated that resident 3 hadn't had any falls that she was aware of. RN 2 stated that if a resident was an assisted smoker, they could only go out of the building when accompanied by assistance. RN 2 stated the door to the smoking area was locked. On 5/22/19 at 11:58 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that when a resident fell and it was unwitnessed, neurocheck would be initiated. CNA 8 stated interventions were relayed by the nurses. CNA 8 stated he was not aware of any falls resident 3 had had. On 5/22/19 at approximately 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when a resident had a fall, the interventions were determined by management. LPN 2 stated that management would come by and notify staff verbally. LPN 2 stated that the intervention was then passed on from shift to shift. LPN 2 stated that the interventions was passed on from nurse to the CN[NAME] On 5/22/19 at 3:16 PM, an observation was made of resident 3. Resident 3 was observed to go towards the back door. This particular door was the designated door which lead out to the smoking area for residents. It had an alarm and required a code to exit. Resident 3 was observed to approach the door, put in the code, unlock the door, and exit the building. Resident 3 was not utilizing any assistive device to walk such as a walker. Resident 3 was observed to make his way to the smoking area. On 5/23/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated that neuro checks were initiated after a fall when the nurse said to do them. CNA 6 stated future falls were prevented by interventions from the nurse. CNA 6 stated each shift was responsible for rounding with the other CNA's and nurse to be aware of who was on fall precautions. CNA 6 stated that a system called a kardex was available to provide information on each resident. CNA 6 stated the kardex was the CNA's reference guide. CNA 6 stated she didn't often work with resident 3 but knew he was one that needs to be watched. On 5/23/19 at 9:47 AM, an interview was conducted with resident 3. Resident 3 stated he could not have cigarettes or a lighter in his room any longer. Resident 3 stated that all he had to do was request cigarettes and a lighter from the nurse and he will be provided with them. Resident 3 stated that he knew the code to the back door and often let himself out. Resident 3 stated there had been times he had been out there alone. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated that the nurse who was working at the time of the fall decided the intervention and informed the rest of the staff. LPN 3 stated she was not concerned about any resident's ability to retain education as an intervention on that hall. LPN 3 stated she did not think resident 3 had any falls. LPN 3 was observed to enter the medical charting system and stated it appeared resident 3 had a fall on 4/11/19. LPN 3 stated interventions for that fall were teaching and educating the resident and frequent monitoring. LPN 3 stated frequent monitoring meant that the CNA's were going in a lot, about every hour to two hours. LPN 3 stated resident 3 had poor mental status and confusion. LPN 3 stated resident 3 required a lot of reminders and reassurance. LPN 3 stated that when resident 3 was in a confused state, he was checked on frequently. LPN 3 stated resident 3 was an independent smoker. LPN 3 stated that if a resident was on supervised smoking, it would be in their orders. LPN 3 stated that staff are aware of when resident 3 goes out so we watch and make sure that he comes back. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated that interventions would be in the computer somewhere. CNA 7 stated she was not aware of any falls resident 3 had had. On 5/23/19 at 11:59 AM, an interview was conducted with CNA 5. CNA 5 stated that neurochecks were initiated after a resident fell . CNA 5 stated that nurses were over interventions. CNA 5 stated that interventions were then passed on from shift to shift in report. When asked if resident 3 had had any falls CNA 5 stated not that I know of and that he didn't require any interventions. On 5/23/19 at 12:53 PM an interview was conducted with the DON. The DON stated that management would develop interventions after a fall. The DON stated that interventions were communicated to staff directly by her or in notes. The DON stated that interventions were documented in the 72 hour event charting which would notify each shift of the new intervention. The DON stated that fall interventions would also be put on the CNA's kardex. The DON stated interventions were decided at the IDT meetings. The DON stated resident 3 had been assessed as safe to be outside but he could not have his own cigarettes or lighter in his room. The DON stated resident 3 was safe to go outside by himself. The DON stated she was unable to recall any falls resident 3 had had. The DON stated that resident 3 did have confusion and would forget things. When concern was expressed over the interventions implemented for resident 3, the DON responded resident 3 was a hard one. The DON stated that resident 3 had ups and down and would get stronger and weaker and go on and off assisted smoking. The DON stated resident 3 would be assessed again. The DON acknowledged the lack of neuro check for 1/19/19 and the lack of a sign in resident 3's room as per the intervention for the 1/2/19 fall. On 5/23/19 a copy of resident 3's kardex was requested from the facility. There was no indication on the kardex that resident 3 required assisted or supervised smoking. 2. Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19 resident 43's medical record was reviewed. Resident 43's nursing progress notes were reviewed and revealed the following: a. On 3/13/2019 at 5:10 PM, the following was revealed: Fall Note, Note Text: Resident shoes stuck to the trim in the entering the bath room and lost his balance and the CNA lowered the resident to the floor. Noted injuries: abrasions to the knees bilaterally, covered the abrasion c (with) skin prep (sic) and bordered gauze, administered Tylenol for pain. VITALS:BP (blood pressure) 103/61 HR (heart rate) 112, TEMP (temperature) 97.5, RR (respiratory rate) 20, o2 (oxygen) 96, room air, neuro checks started, WCTM (will continue to monitor). b. On 3/13/19 at 9:56 PM, a note titled 72 hour event charting was filled out. It stated interventions: Fall and safety precautions maintained, assessment, vital signs, use the call light for help. c. On 3/14/19 at 5:37 PM, a 72 hour event charting note stated interventions: reminders to use call light for assistance, good foot wear, surroundings uncluttered. d. On 3/14/19 at 10:00 PM, a 72 hour event charting note stated interventions: fall precautions maintained, using call light for assistance, uncluttered surroundings. e. On 3/15/19 at 12:17 PM, a 72 hour event charting note stated interventions: reminders to use call light, for assistance, good footware (sic), uncluttered surroundings. (Note: at the time of the fall, resident 43 was wearing shoes, was receiving assistance, and it was not clear if cluttered surroundings had contributed.) There was no follow up interdisciplinary team note in the progress notes. A request was made from the facility for the incident investigation into this fall and none was provided. On 5/22/19 at 11:42 AM an interview was conducted with RN 2. RN 2 stated that resident 43 had a fall a couple of months ago. RN 2 stated that resident 43 was being assisted by a CNA and was bringing his walker into the restroom. RN 2 stated that walker hit the metal piece and he fell . RN 2 could not recall who was assisting resident 43. On 5/22/19 at 11:58 AM, an interview was conducted with CNA 8. CNA 8 stated that he was not aware of any falls that resident 43 had had. On 5/22/19 at 12:15 PM, an interview was conducted with RN 1. RN 1 stated that when a fall occurred, 72 hour fall charting was initiated, as well as the event charting, assessment and risk management. RN 1 stated that risk management was the incident report. On 5/23/19 at 8:45 AM an interview was conducted with CNA 6. CNA 6 stated that resident 43 had a fall recently. CNA 6 did not know whether resident 43 was on any fall precautions. CNA 6 stated that she was aware it had been a witnessed fall and that resident 43 had gotten afriad but did not know any more details. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated resident 43 had not had a fall that she could recall. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated resident 43 hadn't had any falls that she was aware of. On 5/23/19 at 11:59 PM, an interview was conducted with CNA 5. CNA 5 stated she took care of the section in which resident 43 resided 2 to 3 times a week. CNA 5 stated resident 43 had not had any falls she was aware of. On 5/23/19 at 12:53 PM, an interview was conducted with the DON. The DON stated that when a fall occurred, the nurses should initiate a risk management report and event charting. The DON stated that a fall committee and an IDT meeting would then discuss the event and decide on an intervention. The DON stated that the whole process was revamped 2 weeks ago. The DON stated she noticed that an incident report had not been completed for resident 43's fall on 3/13/19. The DON stated that she agreed that the intervention did not match the possible root cause of the fall. 3. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19 resident 32's medical record was reviewed. Resident 32's progress notes revealed the following: a. 11/3/18 at 11:40 PM, a Fall note stated: Resident was coming (sic) back in to the facility from smoking, they (sic) were some visitors, resident drives a power chair, she did not put attention that she was driving too close to them, resident run over visit left foot (this is what visito (sic) stated), this nurse gave resident teaching, to be careful, to take her distance, to slow down, resident understand what she did wrong, after resident was assisted to bed, breathing treatment administered, and also got O2 (oxygen) at 3L (liters) per NC (nasal cannula) to maintain saturations above 90% at time of incident O2 78% with treatment O2 up to 94%. b. 11/7/18 at 5:53 PM, a nurses note stated: PT found on floor in a sitting position with wheelchair directly behind her back. Pt states she was trying to turn her TV and slid from her chair. Pt had a pillow behind her back at time of fall to (sic). Neuro checks started . c. 11/9/18 at 10:44 AM an interdisciplinary team note stated: Review of (fall) on 11/9/18 .interventions: frequent staff monitoring, proper positioning when in w/c (wheelchair), motorized w/c returned to res (resident) . d. 12/16/18 at 1:55 PM, an incident note stated: Res was found outside on the ground next to her electric w/c by guest coming in facility. Res was going outside to smoke and she said her w/c kept turning in circles and she couldn't make it stop and the wheel hit the curb and she fell out. Nurse assessed and she was found to have a (sic) open wound to LLE (left lower extremity) and c/o pain to arm. Res stated she didn't hit her head. Wound to LLE was bandaged d/t (due to) bleeding. e. 12/18/19 at 10:14 AM, a Social Services Note stated: Met with resident to discuss recent fall outside and smoking safety. Resident agreed to let LCSW (Licensed Clinical Social Worker) take cigarettes and put at the nurses station. Resident will get cigarette from nurse station when she goes to smoke and will exit through the back door to smoke at the smoking shack to avoid ice patches in the parking lot. Resident verbally agreed that is she is seen smoking anywhere other than the designated smoking area, she will be put on assisted smoking program and will lose access to her wheelchair because of the safety hazard posed by wheeling through the parking lot in snow/ice conditions. f. 12/18/19 at 1:03 PM, IDT Event Review stated: IDT review of unwitnessed fall on 12/16/18 .patient was found on the ground next to her electric W/C by a guest that was coming into the facility. Patient was going outside to smoke and she states that her W/C kept turning in circles and she could not make it stop and the wheel hit the curb and patient states she fell out. Nurse assessed the patient and found to have open wound to LLE and c/o pain to arm. Patient states she did not hit her head, patient was transferred to (nearby hospital) for there eval Root Cause: likely r/t hitting curb in wheelchair causing her to fall out of chair New Interventions implemented: Resident returned from ER (emergency room ) stiches (sic) placed to LLE .Resident will now keep cigarettes at nurses station, Resident agrees that she will smoke at the designated smoking area and is aware that if she is seen smoking up front she will be put on assisted smoking. g. 1/12/19 at 3:34 AM, 72 Hour charting was initiated and stated: SOB (shortness of breath) with exertion .resident lethargic, mumbling, don't know where she was, saturations where (sic) about 77 (percent) RA (room air) O2 at 3L per nc was started saturation when (sic) to 97% resident needs O2 at 3L per nc at all times, except when to smoke, prior incident resident was outside smoking h. 1/13/19 at 3:24 AM, a 72 hour charting note stated: Resident goes to smoke under supervision, she was upset, angry, it was explained to her that it was for her safety, if she feels dizzy or SOB there is some body next o her to help immediately (sic), resident finally accepted to be under supervision, when (sic) to smoke, resident uses O2 at 3L per NC at all times except when to smoke .saturations before smoking 98% after smoking this Hs (at bed time) 82 RA . i. 1/14/19 at 5:38 AM, a 72 hour Event charting note stated: Resident AA & O (alert and oriented) monitoring saturations before and after smoking, continues using nebulizers, [MEDICATION NAME], O2 at 3L sats RA after smoking 76% with O2 3L sats 96% j. 1/14/19 at 10:00 AM, an IDT Event Review note stated: .came back from smoking. Resident stated to nurse I don't know what happened, i remember I was smoking after that I don't remember .Resident was lethargic and mumbling, saturations where (sic) about 77% on room air. 3 litters (sic) of oxygen place on Resident per orders nasal cannula and saturations went up to 97% and Resident became more alert and oriented .Root Cause: [MEDICAL CONDITION]ly r/t Pt refuses to wear O2 at times with chronic underlying respiratory conditions, goes outside to smoke frequently. New interventions implemented: MD notified, nursing placed oxygen back on and educated resident to stay inside and keep oxygen on. Education on smoking cessation. Nursing to continue to monitor and notify MD of any adverse changes . k. 5/8/19 at 2:18 PM, a nurses note stated: Resident was outside smoking when an aide called for help, LN (Licensed Nurse) went outside and resident was on the ground laying in the smokers shacks in front of her electric W/C. Resident SATS were in the 80's with bluish gray lips. l. 5/9/19 at 10:18 AM, an IDT Event Review note stated: Event description:[NAME] was smoking outside, her w/c frame bent causing her to fall out onto the patio in the prone position; unwitnessed fall, found by CN[NAME] On assessment, superficial abrasions noted to BLE (bilateral lower extremities) . Risk factors: Unsupervised smoker, electric w/c, [MEDICAL CONDITION]-left side .Root Cause: bent w/c frame causing her to fall out of w/c. New interventions: PT evaluation to get w/c fixed; PT post fall assessment, neurological checks per protocol, use of manual wheelchair until electric w/c if (sic) fixed, monitoring abrasion-keep open to air .supervised smoking program . Resident 32 had a quarterly fall assessment completed on 3/6/19. It was titled the Morse fall scale. The assessment revealed to the question Has the resident ever fallen before? the answer recorded was No. The result of the assessment was that resident 32 was a moderate fall risk. (Note: resident 32 had had 3 falls from (MONTH) (YEAR) to 3/6/19.) A wheelchair safety evaluation was completed on 1/18/19. The previous power chair assessment had been completed on 11/7/18. There was not a wheelchair safety evaluation completed at the time of the fall on 12/16/18 in which the resident stated she kept turning in circles and she couldn't make it (the wheelchair) stop hit the curb, and .fell out. On 5/22/19 at 11:42 AM, an interview was conducted with RN 2. RN 2 stated that she was not aware of incidences with resident 32 recently. On 5/22/19 at 11:58 AM, an interview was conducted with CNA 8. CNA 8 stated resident 32 has had a couple of falls and fallen while smoking. On 5/23/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated resident 32 was a fall risk and was very anxious. When asked if resident 6 had any falls or required interventions, CNA 6 stated, there should be a note if she's had a fall or interventions. CNA 6 stated that a system called a kardex was available to provide information on each resident. CNA 6 stated the kardex was the CNA's reference guide. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated she was aware resident 32 had had incidences but was unable to provide details. LPN 3 was observed to access the facility's medical charting system. LPN 3 stated that resident 32's last incident had occurred on 4/18/19. LPN 3 stated resident 32's oxygen was low. LPN 3 stated that's why we supervise (her) now. LPN 3 stated it took a lot of reminding and teaching with her. LPN 3 stated resident 32 was on supervised smoking. LPN 3 stated that if a resident was on supervised smoking, it would be in their orders. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated that resident 32 had been leaning over while she was smoking outside. CNA 7 stated that the intervention for that fall was to put her in a manual wheelchair and have her be on supervised smoking. On 5/23/19 at 11:59 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 32 had falls. CNA 5 stated that resident 32 had fallen outside while on a smoke break. CNA 5 stated that the intervention was to take away resident 32's cigarettes at night. CNA 5 stated that resident 32 was an independent smoker who could take herself outside. A copy of resident 32's kardex was requested from the facility. It revealed under the safety section that resident 32 could smoke supervised. Resident 32's order history was requested from (MONTH) (YEAR) to the time of the survey. There was no order indicating that resident 32 had ever been on a supervised or assisted smoking program. On 5/23/19 at 12:08 PM an interview was conducted with the Therapy Director (TD). The TD stated that resident 32 had multiple events with her powerchair. The TD stated that when we do the tests (wheelchair driving tests) she passes with flying colors. The TD stated that resident 32 was only allowed to go to the smoking area and then back in. The TD stated she has fallen out of her chair and hit her leg. The TD agreed that resident 32's ability to safely drive the power wheelchair should have been assessed at that time. The TD stated that the medical company who maintains resident 32's power chair had come out and fixed it before. The TD stated that he did not recall having resident 32's powerchair fixed or looked at in May. On 5/23/19 at 12:53 PM an interview was conducted with the DON. The DON stated if a resident had an incident involving their wheelchair, then they would be referred to physical therapy for a driving test. The DON stated therapy attended the IDT meetings and referrals often happened then. The DON acknowledged that resident 32's wheelchair driving safety should have been assessed after the incident 12/16/18. 4. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 7:40 AM, an observation was made of resident 13 in his room. Resident 13 had debris scattered around his bed. Resident 13 was interviewed. Resident 13 stated that he used to walk but now he rides in a wheelchair. On 5/23/19 a review of resident 13's electronic medical record was completed. A review of fall incident reports revealed the following falls: a. 11/4/18 at 2:01 AM b. 12/7/18 at 8:34 PM c. 1/6/19 at 1:02 PM d. 1/9/19 at 5:50 AM e. 2/17/19 at 2:00 PM Resident 13's falls care plan included the following interventions that were initiated on 11/18/18: a. Add signage to room reminding resident to use urinal at bed side when needed to urinate/and reminder to use call light when needing assistance . b. After each meals have resident be offered toileting, if he wants to be placed to bed or in recliner, or go read newspaper in activities . c. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . d. Educate staff not to leave resident on toilet unattended . e. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility . f. Ensure that the resident is wearing appropriate footwear and/or non-skid socks when ambulating or mobilizing in w/c . g. Resident is to be a 2 person extensive assist with all transfers. Standing recliner in room & sit-to-stand Hoyer from bed & manual wheelchair . h. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to cause (TRUNCATED) | 2020-09-01 |