cms_UT: 83
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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83 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 656 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that the facility did not develop a person-centered comprehensive care plan to meet the resident's medical, physical, mental or psychosocial needs. Specifically, a bladder incontinence care plan did not address how often incontinence care was to be provided. Resident identifiers: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. An annual Minimum Data Set (MDS) Assessment was completed by facility staff on 4/17/17. The facility staff assessed resident 9 as being always incontinence of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. A quarterly MDS assessment was completed by facility staff on 3/28/18. The facility staff assessed resident 9 as being frequently incontinence or urine. The facility staff documented that resident 9 was not on a toileting program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. Review of the care plans developed for resident 9 revealed a bladder incontinence care plan that was developed on 3/1/18. The facility staff documented, (Resident 9) has bladder incontinence related to Dementia, Impaired Mobility. The goal developed was, (Resident 9) will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions developed to achieve the goal included, Utilizes briefs lined with incontinence pad, Clean peri-area with each incontinence episode, and Encourage fluids during the day to have adequate urinary output and prevent alterations in hydration. (Note: The bladder incontinence care plan did not include how often resident 9 was to be toileted or checked for incontinence episodes.) Resident 9 was continuously observed for toileting and repositioning on 6/19/18 from 9:52 AM to 12:27 PM. (Note: The survey staff stood outside resident 9's room, across the hall, which allowed for resident 9 to remain in line-of-sight at all times; and observed resident 9 while she was in the dining room.) The following was observed: a. At 9:52 AM, resident 9 was propelled by her hospice Certified Nurse Assistant (CNA) in her wheelchair from the shower room to her room. Resident 9's oxygen was infusing. b. At 9:56 AM, a hospice CNA exited resident 9's room. Resident 9 was observed to be sitting in her wheelchair with a green blanket placed over her. Resident 9's oxygen was infusing at 3 liters/nasal canula. The door to resident 9's room remained open. c. At 11:03 AM, a hospice nurse entered resident 9's room and assessed resident 9. Resident 9's door remained open and no care was provided to resident 9. d. At 11:35 AM, resident 9 remained sitting in her wheelchair with a green blanket placed over her. No personal cares had been provided. e. At 11:53 AM, two CNA's entered resident 9's room. One of the CNA's stated, Oh, she's (resident 9) already up. Resident 9 was propelled to the dining room for her lunch meal. Resident 9 was not observed to be checked for incontinence and resident 9 was not repositioned. f. At 12:27 PM, resident 9 was served cut up chicken, rice, green beans, peaches and milk. The continuous observation ended as resident 9 was eating her lunch. It should be noted that multiple facility employees including the Director of Nursing, housekeeping and the Social Services Worker, entered resident 9's room during the observation time. However, resident 9 was not checked for incontinence or repositioned. On 6/19/18 at 1:25 PM, resident 9 was propelled from the lunch room to her room, accompanied by Certified Nursing Assistant (CNA) 6 and CNA 7. CNA 6 and 7 transferred resident 9 via a mechanical lift. Resident 9's groin area and buttock area was visibly soiled and with a urine odor. CNA 6 and 7 stated that resident 9 was to be toileted after breakfast and lunch. CNA 7 obtained a clean brief and placed an incontinence liner inside the brief and stated that resident 9 was a heavy wetter. Resident 9's urine soaked brief with incontinence pad was weighed by facility staff. The incontinence products weighed 1.4 lbs. On 6/19/18 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 was to be toileted every couple of hours between breakfast and lunch and after lunch. On 6/19/18 at 2:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 9 was to be toileted every 2 hours to see if she was dry. | 2020-09-01 |