cms_UT: 88
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 88 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 690 | 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 a resident who was incontinent of urine received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident who was incontinent was not checked or toileted for 3 1/2 hours. 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. 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 incontinent 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. 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 incontinent episodes.) Resident 9 was continuously observed (the survey staff stood outside resident 9's room, across the hall, which allowed for resident 9 to remain in direct line-of-sight at all times; and survey staff observed resident 9 while she was in the dining room) for toileting and repositioning on 6/19/18 from 9:52 AM to 12:27 PM. The following was observed: a. 9:52 AM, resident 9 was propelled by her hospice Certified Nurse Assistant (CNA) in her wheelchair from the shower room to her room. b. 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. The door to resident 9's room remained open. c. 11:03 AM, a hospice nurse entered resident 9's room and assessed resident 9. Resident 9's room remained open and no care was provided to resident 9. d. 11:35 AM, resident 9 remained sitting in her wheelchair with a green blanket placed over her. No personal cares had been provided. e. 11:53 AM, two CNA's approached 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 checked for incontinence and resident 9 was not repositioned. f. 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 CNA 6 and CNA 7. CNA 6 and 7 transferred resident 9 via a mechanical lift from the wheelchair to the bed. Resident 9's groin area and buttock area was visibly soiled and smelled of urine. The urine soaked brief and incontinence liner were removed and placed in the garbage can. CNA 7 obtained a clean brief and placed an incontinence liner inside the brief and stated that resident 9 was a heavy wetter. CNA 6 and 7 stated that resident 9 was to be toileted after breakfast and lunch. It should be noted that resident 9's urine soaked brief with incontinence pad was weighed. 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 |