cms_UT: 7
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 697 | 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 1 of 30 sampled resident that the facility did not ensure that pain management was provided to residents who require such services. Specifically, a resident sustained [REDACTED]. Resident identifier 64. Findings include: Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 11:30 AM, resident 64 was found on the floor in an unoccupied room. 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. Registered Nurse (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 Certified Nurse Assistant (CNA) 3 assisting resident 64 into a sitting position and then transfer her into the 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 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 could normally stand with assistance for incontinence brief changes and that her current inability to stand was a change from her baseline. 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 her left hip was touched and I don't like that she is this quiet. At this time CNA 3 and the MD exited resident 64's room. 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 while grabbing resident 64 on the left hip and left femur for positioning. Resident 64 was agitated and repeatedly stated owe during the position change. On 1/10/18 resident 64's medical records was reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] Tablet 325 milligrams (mg), give 2 tablets via [DEVICE] (gastrostomy tube) every 4 hours as needed for mild pain. b. [MEDICATION NAME] Solution 250 mg/5 milliliter (ml), give 18 ml via [DEVICE] two times a day for pain. c. [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet via [DEVICE] every 6 hours as needed for breakthrough pain. d. Monitor Level of pain every shift. Review of Medication Administration Record [REDACTED]. At 3:20 PM [MEDICATION NAME] 7.5-325 mg was administered with a numeric pain level of 5 documented. Review of care plan for pain revealed a focus of has chronic pain related to MS, pain to left knee, swelling, vascular malformation, pressure ulcer, depression, (and) decreased mobility. Interventions included the following: a. Administer [MEDICATION NAME] medication as per orders, give 1/2 hour before treatment or care. b. Monitor/record/report to Nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). c. Pain assessment every shift. d. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities relate to signs or symptoms or complaints of pain or discomfort. Review of nursing progress notes revealed the following: a. On 1/10/18 at 1:22 PM, Resident is Anxious/Agitation. Resident is Restless. and PAIN: Yes unable to assess Pnl (pain level) 5 - 1/10/18 at 17:46 (5:46 PM) Pain scale: PAINAD (Pain Assessment in Advanced Dementia) unable to assess pain medication, repositioning, dim lights. b. On 1/11/18 at 5:47 PM, LATE ENTRY 1/10/18 at 1500 (3:00 PM): resident appeared to be very restless. Resident repeatedly was calling out. Res (resident) kept grabbing at the side of her bed and appeared to be fidgeting. Res kept repeating the same phrase over and over. Res was unable to console or distract. Facial grimacing was noted. Res body appeared very tense and rigid. One of resident's hands were clenched. Out of baseline for resident. c. On 1/10/18 at 6:35 PM, Activities reported resident had fallen on the floor in room [ROOM NUMBER] on D hall. Upon assessment, res was found lying on L (left) side face to the floor. Res confused, not oriented to person, place, time, and situation. ROM (range of motion) WNL (within normal limits) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Facial grimacing noted. Res appeared very restless and tense. Review of the neurological assessment on 1/10/18 revealed check marks in the column of response to pain starting at 11:45 AM and continued until 2:30 PM. On 1/10/18 at 3:10 PM an interview was conducted with RN 1. RN 1 stated that the check marks through the pain column on the neurological assessment indicated that the resident has pain and one of the PAINAD scale identifiers. RN 1 stated that the PAINAD score is used to assess pain in non-verbal residents such as resident 64. RN 1 stated resident 64 currently has a PAINAD score of 5 with the following identifiers: facial grimacing, tense, difficult to console, and occasional moan. It should be noted that resident 64 received her first dose of PRN (as needed) pain medication [MEDICATION NAME] after the surveyor inquired about pain assessments for non-verbal residents. On 1/11/18 at 1:55 PM a repeat interview was conducted with RN 1. RN 1 stated that no CNA reported that resident 64 was complaining of pain on 1/10/18 after her fall and during incontinence care. RN 1 further stated that with resident 64 he would be careful with weight bearing, ROM, and movement of the affected extremity until confirmation of no injury was obtained from the X-ray. On 1/11/18 at 2:25 PM an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation of staff after a resident has sustained a fall was to do a head to toe assessment and to start neurological assessments per protocol. The DON further stated that resident 64 had arthritis in her left knee that caused her chronic pain. On 1/16/18 at 8:32 AM a repeat interview was conducted with the DON. The DON stated that her expectation of staff was to assess the resident every time complaints of pain were expressed, especially since resident 64 was non-verbal and could be communicating other needs this way. The DON stated that the staff were expected to assess a resident for pain post fall and that the CNA's should be communicating the complaints of pain to the RN so the RN can assess the resident. | 2020-09-01 |