cms_UT: 84
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
84 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 658 | D | 1 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined for 1 of 31 sample residents, that the facility did not ensure that services were provided as outlined by the comprehensive care plan. Specifically, a resident was not transferred with a two person assist which resulted in the resident being lowered to the floor. Resident identifier: 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. On 11/15/17, a care plan related to resident 9's risk for falls was developed. The care plan documented that resident 9 had a history of [REDACTED]. The goal developed was, (Resident 9) will not sustain serious injury through the review date. On 3/1/18, an intervention of Staff educated to assist with two assist for transfers/gait belt; encourage the use of the walker was implemented. On 5/28/18 at 2:16 PM, a facility nurse documented in a progress note, Was called to resident room by the aid. Resident laying on the floor by her recliner. No injuries. Residnet (sic) did not hit her head, she was lowered to the floor during transferring from the wheelchair to her recliner. Staff to continue to monitor. On 5/30/18 at 11:18 AM, a facility nurse documented in a progress note, IDT (Interdisciplinary Team) Fall Review: Refer to PT (Physical Therapy) to increase strength to BLE (Bilateral Lower Extremities) and improve safety with transfers. (Note: There was not an investigation into the fall to ensure that the care plan was followed and interventions to prevent resident 9 from falling were implemented.) On 6/19/18 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to determine who was transferring resident 9 at the time resident 9 was lowered to the floor or whether two staff members were transferring resident 9 as care planned. | 2020-09-01 |