cms_WY: 94
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 94 | BONNIE BLUEJACKET MEMORIAL NURSING HOME | 535019 | 388 SOUTH US HWY 20 | BASIN | WY | 82410 | 2017-04-06 | 309 | E | 0 | 1 | 508H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, and medical record review, the facility failed to ensure pain monitoring was implemented for 3 of 3 sample residents (#17, #18, #21) with identified pain. Further, the facility failed to assess 1 of 3 sample residents (#12) after a fall. The findings were: 1. Review of the 3/27/17 significant change MDS assessment showed resident #17 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 15 (cognitively intact), was able to understand and be understood, had scheduled and as needed pain medication, and reported occasional pain of 7 out of 10. Review of the Pain care plan dated 8/31/16 showed approaches for pain included 1. Monitor pain 2. Non-drug interventions 3. Administer pain medications as ordered. The following concerns were identified: a. Review of a nursing note dated 3/29/17 and timed 2:14 PM showed the resident received an order for [REDACTED]. There was no evidence the medication effectiveness was assessed after administration. b. Review of the MAR for (YEAR) showed no evidence the resident was routinely assessed for pain. c. Interview with the resident on 4/5/17 at 1:50 PM revealed s/he did not think the CNAs always reported it to the nurse when s/he asked for pain medication, because sometimes s/he would not get any pain medication. d. Interview with a family member of the resident on 4/5/17 at 9:40 AM revealed the resident requested pain medication at night and the CNA would not tell the nurse. The resident had to wait until the next shift arrived to receive the medication. Further, the family member stated the resident would turn on his/her call light and staff would take more than an hour to answer it or turn the call light off without assisting the resident. 2. Review of the 2/13/17 admission MDS assessment showed resident #18 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 12 (cognitively intact), was able to understand and make self understood, and reported occasional pain of 6 out of 10. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the Pain care plan last reviewed on 2/13/17 showed approaches for pain included 1. Monitor pain 2. Non-drug interventions 3. Administer pain medications as ordered. 4. Establish causative factors and ways to alleviate them b. Review of the MAR for (YEAR) showed no evidence the resident was routinely assessed for pain. 3. Review of the admission assessment dated [DATE] showed resident #21 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 6 (severely impaired), was able to understand and make self understood, received as needed pain medication, and reported occasional pain of 6 out of 10. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the Pain care plan last reviewed on 10/26/16 showed approaches for pain included 1. Monitor pain Chronic 2. Non-drug interventions Reposition, elevation, distraction 3. Administer pain medications as ordered. b. Review of the MAR for (MONTH) (YEAR) showed no evidence the resident was routinely assessed for pain. 4. Interview with the DON on 4/5/17 at 2:07 PM revealed staff should assess residents' medication effectiveness after administering as needed pain medications; however, the facility did not routinely monitor residents for pain. 5. Review of a nurse's note dated 3/31/17 and timed 7 AM showed resident #12 was found on (his/her) knees in (his/her) bathroom. The following concerns were identified: a. Review of the subsequent nursing notes showed no evidence the resident was monitored for injuries following the fall. Further, there was no evidence the resident was assessed for a possible head injury. b. Interview with the DON on 4/6/17 at 9:10 AM revealed the resident should have been monitored after the fall and neurological assessments should be completed after unwitnessed falls. | 2020-09-01 |