cms_WY: 80
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 80 | BONNIE BLUEJACKET MEMORIAL NURSING HOME | 535019 | 388 SOUTH US HWY 20 | BASIN | WY | 82410 | 2019-03-27 | 657 | E | 0 | 1 | GU4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and resident, family and staff interview, the facility failed to ensure the individualized person-centered care plan was revised as needed to reflect the resident's current needs for 5 of 16 sample residents (#1, #14, #15, #23, #26). The findings were: 1. Review of the medical record showed resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/25/19 at 9:44 AM showed the resident was resting in bed. Interview with the resident at that time revealed s/he did not get out of bed due to arthritis and pain. S/he further stated s/he was not receiving therapy. The following concerns were identified: a. Review of physical therapy notes dated 2/26/19 showed the resident became agitated and refused care when they saw her/him. b. Interview on 3/26/19 at 3:03 PM with LPN #1 revealed the resident refused to get of out bed and refused to move his/her legs and left arm. She added the resident refused repositioning. c. Review of the MDS showed a quarterly assessment was completed on 3/11/19. Review of the care plan showed a review date of 11/14/19; 4 months prior to latest quarterly assessment. Further review of the care plan failed to show interventions to address the resident's pain. 2. Review of the medical record showed resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The following concerns were identified: a. Interview on 3/25/19 at 11:36 AM with the resident's brother revealed the resident had constant pain in his/her neck and was unable to take the bus because it hurt too much. The facility was going to get a special pillow to support the resident's neck. He further stated s/he had a hearing aid that caused pain, and he thought the facility was going to fix it but was not sure. b. Review of the MDS showed a quarterly assessment was completed on 3/4/19. Further review showed the resident had a pain level of 5 on a scale of 10 (with 1 being the least pain and 10 being the most), and received as needed pain medication, the resident also had a hearing aid. c. Review of the care plan showed it was last reviewed 12/17/18, and failed to show interventions that would help decrease the pain, and what made the pain worse. d. Review of the Care Plan Meeting Summary dated 3/4/19 showed the facility purchased a neck pillow to ease some of the vehicle motion. Review of the care plan failed to show this intervention. e. Interview with LPN #1 on 3/26/19 at 3:53 PM revealed the resident had a hearing aid which caused him/her pain. She stated the facility had it fitted to the ear, and had cleaned the ear, but the resident could only wear it for a couple days before s/he complained of pain. Review of the care plan failed to have a plan for the hearing aid. 3. Review of the medical record showed resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued observations showed staff redirected the resident to the common area and included him/her in the activities. Interview on 3/26/19 at 11:30 AM with LPN #1 revealed the resident wandered but had not tried to walk out the door. She added they tried to place a wander guard multiple times but the resident removed it. When staff saw the resident walk towards the hospital they walked with the resident and redirected him/her. She further stated staff sat with the resident during meals and encouraged him/her to eat. The following concerns were identified: a. Review of the MDS showed a quarterly assessment was completed on 2/4/19. b. Review of the care plan showed the last review date was 11/29/18. Further review of the care plan showed wander alarm check every shift, and failed to show interventions used when resident removed the wander guard. 4. Review of the medical record showed resident #23 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/25/19 at 3:29 PM showed the resident had an ace wrap dressing and heel protector to the right lower leg. Interview with the resident at this time revealed s/he had pressure ulcer on his/her heel and was seeing a physician who managed the wound. Review of the care plan with a review date of 1/18/19 failed to show evidence of a wound. Interview on 3/26/19 at 10 AM with the DON revealed the care plan was not revised to reflect the wound and wound care. 5. Review of the 2/4/19 MDS assessment showed resident #26 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Further review showed the resident had a BIMS score of 6/15 (severe cognitive impairment); required the extensive assistance of one staff member for bed mobility, transfers, dressing, and toilet use; required the limited assistance of one staff member for locomotion on the unit using a wheelchair or walker; and used a bed and chair alarm daily. The following concerns were identified: a. Observation on 3/25/19 at 3:01 PM showed an alarm was attached to the resident's wheelchair. b. Interview with CNA #1 on 3/26/19 at 2:08 PM revealed the resident used a chair and bed alarm daily. c. Review of a nursing note dated 11/28/18 showed NDO (new doctor order) for bed & chair alarms d/t (due to) res (resident) crawling out of bed on (resident) own and falling out of bed. d. Review of the falls care plan, last reviewed 11/26/18, did not show the use of a bed or chair alarm. e. Interview with the DON on 3/26/19 at 9:34 AM confirmed the care plan did not include the use of the chair or bed alarm. 6. Interview with the DON on 3/26/19 at 10 AM revealed some interventions were written in the care plans, but they had not been updated with the last MDS assessments. | 2020-09-01 |