GOOD SAMARITAN CARE CENTER Facility I.D. Number 0011650 Date of Survey: 2/28/02 Complaint Investigation and Incident Report Investigation of 2/15/02 “A” violation(s): The facility must provide the necessary care and services toattain and 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. All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents. 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 comprehensive assessment, individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. 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. The plan shall be reviewed at least every three months. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. These regulations are not met as evidenced by: A. Based on record review and staff interviews, the facility neglected to ensure safeguards were in place to monitor/prevent suicide attempts for a resident with a known history of 2 previous attempts to commit suicide. Resident made a third attempt to take own life after admission to the facility.(R7) Findings Include: 1. R7 is a 94 year old with medical diagnoses including Depression. R7 was admitted to the facility on 01/31/02 from a local hospital with a diagnosis of attempted drug overdose. Per review of the history and physical from the hospital, R7 had taken a dozen 1mg. Ativan tablets on 01/27/02. Also per the history, R7 had attempted to take own life in January of 2001. The history does not indicate method what was attempted at that time. A copy of a Mental health consult completed on 01/28/02, while R7 was a patient in the hospital, was found in the record that stated patient admitted taking 12 Atrivan, and patient reported previous attempts to end own life. Patient denied being suicidal at this time, however stated “I just needed to take more or I could just drive my car into the river.” Patient indicated that they will be suicidal if faced with nursing home admission. The recommendation made by the mental health worker was “even though patient denies being suicidal at this time, take all suicide precautions due to patients history.” Per interview with E6 (SS) on 02/21/02, the facility did not institute any suicide precautions for R7 when R7 was admitted because the resident told staff, family and physician that they would not make another attempt on own life. Surveyor asked E6 if she had been made a aware of the mental health consult in the record and was she aware of the recommendations made as a result of the consult. E6 said that she had never seen the consult form prior to surveyor showing it to her and was not aware of any recommendations that had been made. Additional interviews with E2, (DON) E5 (MDS/care plan-coordinator), E11 (LPN) who was the admitting nurse, and E1 (Administrator) all relayed that they were not aware of the consultation form nor it’s recommendations. Per review of the resident record on 02/15/02 E6 charted that R7 had made verbal statements that R7 would “be better off dead and so would everyone else.” Per review of R7's assessment completed on 02/13/02, (mood and behavior), R7 made negative statements that R7 would “be better off dead and so would everyone else.” Per review of R7's assessment completed on 02/13/02, (mood and behavior), R7 made negative statements such as “Nothing matters; Would rather be dead; What’s the use; Regrets having lived so long; Let me die.” Per review of R7's individual plan of care completed 02/08/02, there are no stated problems that would indicate the facility’s prior knowledge of R7's suicide attempts and no individual approaches to alert staff of potential recurrence of suicidal ideas. Per review of incident report, R7 was found in his bed at 6P.M. on 2/15/02, the bed was covered in blood, and the resident had a self inflicted cut to his left wrist approximately ?4"x" 1/4" x 1/2".’ The resident had slit his wrist with a razor blade. The investigation done by the facility indicates that R7's daughter had brought him the razors approximately a week prior to the actual incident because he complained of the disposable ones used by the facility. R7 was transferred to a local hospital. Per interview with E1 on 02/26/02 at approximately 2:30P.M., there is a possibility that R7 will return to the facility after his release from the psychiatric unit. The facility did not have a plan in place to ensure R7's safety and there is not an identified method in place for staff to screen other residents with a diagnosis of depression to prevent possible suicide attempts. B. Based on staff and resident interviews and record review, the facility neglected to assess care needs and causative factors, neglected to supervise resident resulting in injury, neglected to assess and provide pain management, neglected to update the care plan and neglected to provide care to maintain dignity for 1 of 5 resident on the sample. (R-1) Findings Include: 1. R1 is a 97 year old resident with diagnoses which include Dementia with Agitation, Major Depression and Attendant Anxiety. R1's Annual Minimum Data Set (MDS) done on 1/8/02 indicates cognitive skills for decision making (2) which is moderately impaired. Per interview with R1, interview with E2 (RN/Director of Nurses) and E6 (Social Service Designee) R1 answers yes and no questions. R1 had 3 falls with injury on 9/25/01, 1/25/02 and 2/10/02. Per record review, R1 flipped her wheelchair during all incidents. R1 had her trunk restraint in place and all falls were unwitnessed. The facility has not assessed R1 for causative factors that may influence the number of falls occurring. Per record review, fall assessments are done quarterly and not done after a fall. The fall assessment only identifies if a resident is at risk for falls. R1 does not have a fall assessment to identify pattern, assess type and causative factor for the 9/25/01, 1/25/02 and 2/10/02 falls. R1's first fall on 9/25/01 resulted in a left hip fracture. The second fall occurred on 1/25/02 resulting in a deep forehead laceration, deep left calf laceration, skin tears on both forearms and periorbital ecchymosis A Physical Therapy (PT) recommendation was made after the 1/25/02 fall to use a drop seat (wedge cushion). Per interview with E1 (administrator) and E2, confirmed the recommendation was not implemented until 2/11/02, which is after the third fall. Per interview with E2 on 2/13/02 at 2 PM, confirmed she was unaware of PT recommendation of drop seat. The third fall occurred on 2/10/02 resulting in a new deep left lateral forehead laceration, shallow laceration on the nose bridge and left chin. The only risk to fall form is used to assess for high/low risk. This was all confirmed with E2 (DON). R1's 1/7/02 Physical Restraint resident assessment protocol summary: Will proceed with restraints. Needs trunk restraint when up in wheelchair to prevent falls. Needs assist with all transfers. R1 does not have an assessment to identify when the restraint was initiated, least restrictive used, reductions attempted and/or alternatives. R1 is identified at high risk for falls. This was all confirmed with E2. On 9/25/01, R1 had a physician's order to call R1's physician if continues to have pain in the left hip or unable to walk. R1 has no assessment for the pain. R1's 9/26/01 nurses notes show R1 continues to complain of pain to the left hip on movement. Per record review, no indication R1 received Tylenol whenever necessary ever necessary for yelling on 9/29/01. R1's 10/2/01 nurses notes documentation shows, resident yelling and states "I hurt all over." Per R1's Medication Administration Record (MAR), no indication Tylenol was given until 10/3/01. Per R1's MAR, Tylenol was given on 10/4 for yelling complaint of pain with no response to effectiveness, 10/10 for temp with no response to effectiveness, 10/13 for yelling/general discomfort, 10/17 for discomfort/yelling with no response to effectiveness, 10/18 for yelling/restless, 10/25 for restless/complaint of leg pain and on 10/29 for restless/complaint of pain with no response of effectiveness. R1's 10/9/01 assessment, does not indicate pain. R1 had falls with injury on 1/25/02 and 2/10/02 resulting in sutures with deep facial lacerations and a deep leg laceration. R1 does not have a pain assessment or pain monitoring. E2 confirmed no pain assessment and no indication of R1's pain being monitored. The facility neglected to update R1's care plan in regards to R1's 9/25/01 fall. R1's Radiology report of 9/25/01, there is probably a non-displaced fracture of the neck of the left femur. R1's 9/25/01 physician's order, call physician if continues to have pain in left hip or unable to walk. R1's 9/27/01 physician's order, activity restricted to bedrest or wheelchair with non- weight bearing until further notice. R1's 10/17/02 physicians's progress note: potential nondisplaced left hip fracture being allowed to heal to potential union without pinning. E2 confirmed the care plan was not updated to include these areas and no new approaches added to prevent accidents from reoccurring. Per record review, a Physical Therapy Evaluation (PT) was attempted on 1/29/02. Per interview with Z1, Z1 came to visit R1 on 1/29/02 and found R1 inappropriately restrained. R1 was sitting in a geri-chair in the hallway across from the 300 Hall Nurses Station with visitors and residents present. This was confirmed with E2. Per interview with Z1, Z1 was upset when she found R1 sitting in the hallway with her feet strapped down in a geri-chair with others present. Per interview with E2, R1 was being observed by nursing at the time of the PT evaluation incident. Per E2, PT was caring for another resident at the time of the incident and not in the area to observe R1. |