COTTONWOOD HEALTH CARE CENTER
Facility I.D. Number 0043513
Date of Survey: 01/24/02
Notice of Violation:03/28/02
Incident Report Investigation of 01/15/02
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
The DON shall oversee the nursing services of the facility including:
Planning an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition.
These requirements are not met as evidenced by:
Based on record review, interview, and observation, the facility failed to place 1 sampled resident (R1) who made statements of self harm on 1:1 supervision despite mental health evaluation recommendations; failed to assess R1's need for supervision related to recent statements of self harm; and failed to revise care plan regarding individualized approaches to protect R1 from self harm. R1 broke a light bulb and cut her wrist requiring 6 stitches.
Admission record for R1 indicates that R1 was admitted to the facility on 12/18/01. Admission notes of E3 (Psycho Social Rehabilitation Counselor/PRSC) on 12/18/01 state "Resident is a readmit. She is 33 years old. Her current diagnosis is Schizoaffective Disorder and Bipolar Disorder, Borderline Personality. She has a history of self abuse due to her mental illness."
Nursing note dated 1/11/02 at 10:15 p.m. quotes R1 as saying "I just want to pull my skin off. Remains 1:1 (one to one) with CNA (Certified Nursing Assistant)."
According to nursing note dated (Saturday) 1/12/02 at 1:40 p.m., resident was sent to the hospital emergency room for psychiatric evaluation by Z1 (Community Mental Health Therapist). Per nursing note by E5 (Licensed Practical Nurse/LPN) on 1/12/02 at 10 p.m., "(Z1) phoned to relate resident ready to return. 1) Should remain on 1:1." Notes by Z1 for this visit state, "Resident to return to facility and remain on 1:1 for statements of self harm. Contacted (facility) and recommendation accepted. Spoke to (E8) (LPN) to inform(ed) her of (R1)'s status and explained the continued need for 1:1 supervision. (E8) stated they would continue the supervision and send someone to come and get (R1)."
Nursing notes dated 1/12/02 (after R1's return to the facility), and subsequent nursing notes dated 1/13/02, 1/14/02, and 1/15/02 do not contain any documented evidence that R1 was placed on 1:1 supervision.
E2 (Director of Nursing) confirmed during interview on 1/18/02 at 11:45 a.m. that "1:1 is our judgement to put on and take off...if a resident is on 1:1 status, that is documented in the nursing notes...".
Nursing notes dated 1/16/02 at 12:50 a.m. document that on 1/15/02 at 8:10 p.m., R1 cut her left wrist with a crushed light bulb, requiring an emergency room visit and 6 stitches.
During interview with R1 on 1/23/02 at 1:05 p.m. in the facility, R1 stated "Both times I cut myself with the bulbs, I was alone. If I had not told the staff, no one would have known." R1 continued "The therapist I saw in the emergency room said he was going to have me stay on 1:1 when I came back. I was not on 1:1 though. I was alone after coming back."
Facility policy for Risk of Suicide states that "Suicidal residents will be placed on these (special precautions) for at least three days, after which the PRSC/DON or Administrator will assess the resident and determine whether the precaution could be lifted, changed to in-house watch, or continued for another period of time." During interview with E2 on 1/18/02, E2 was asked to show the reassessment of R1 by E1, E2, or E3 (per facility policy) done to determine R1's readiness to be released from 1:1 status. E2 verified that an evaluation had not been done and could not find documentation that that R1 had been placed on 1:1 status following the evaluation by Z1 on 1/12/02. E2 verified that she was unaware of the three days monitoring and the requirement that a PRSC, DON, or Administrator was to evaluate the resident before discontinuing special precautions. E2 verified in this interview that it was not done following the facility policy.
During interview with E4 (Care Plan Coordinator) on 1/18/02 at 11:00 a.m., E4 verified that R1's care plan had not been updated until 1/18/02 at 9:45 a.m. to include individualized approaches to address R1's statements of self harm.