Alden Wentworth Rehab & Health Care Center Facility I.D. Number: 0026435 Date of Survey: 08/05/2003 Complaint Investigation "A" VIOLATION(S): 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. 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. These requirements are not met as evidenced by: Based on staff interview, record review and review of the facility's Safety and Supervision of Residents policy, the facility failed to prevent one resident (R7) from a fall on 06/21/03 which resulted in emergency hospitalization. The facility also failed to follow R7's plan of care for continuing supervision and failed to adequately monitor R7 (who is blind and assessed as high risk for falls). Findings Include: R7 was a 80-year-old admitted to the facility on 03/21/01 with diagnoses including blindness, glaucoma, dementia, hypertension, respiratory failure, cardiomegaly, pancreatitis and dysphagia. R7 was totally dependent on staff for all activities of daily living. Review of the full Minimum Data Set (MDS) dated 01/27/03 for R7 reveals that R7 scored 2 in cognitive skill (moderate impairment). R7 was also scored as 3/2 (extensive assist/one person physical assist) for locomotion on and off the unit. The Monthly Nursing Summary dated 05/03/03 and the fall assessment dated 04/09/03 for R7 revealed that R7 scores 15 in falls (10 + plus equals High Risk). No other current assessments were found. Review of nurses notes from 04/23/03 - 06/21/03 show that R7 was ambulating with an unsteady gait and attempting to climb out of bed prior to his injury. Per incident report of 06/21/03 at 6:45P.M., R7 got up from his chair unsupervised at the table and fell from a standing position losing consciousness. R7 was coded and transferred to a local hospital. R7 was admitted into the trauma unit at a local hospital on 06/21/03 with a diagnosis of Rule Out Central Spinal Syndrome. R7 expired on 07/04/03. Per interview with Z1 (family member) on 07/29/03 at 7:52P.M., R7 had injuries of a broken neck and several broken vertebrae when admitted to the hospital on 07/04/03. According to interview with E6 (Certified Nurse's Aide) per telephone on 07/30/03 at 1:30P.M., E6 stated: "There were 2 CNAs on the skilled unit floor with about 68-70 residents. We were dividing time to watch day room." Surveyor asked E6 where she was working at the time R7 fell. E6 stated, " I was passing trays at the other end of the hall by Room 209. At about 6:30P.M. E8 called me. E8 (CNA) said I needed to come into the dayroom. I knew something was wrong. I noted a resident on the floor. We called the nurse (E9) at the time of the incident. E8 was dividing his time between monitoring the dayroom and passing linen. E8 heard a resident say someone has fallen. E8 looked into dayroom and saw R7 on the floor." Surveyor asked E6, how was R7 laying on the floor? E8 stated, "R7 was lying face down with his head turned to the side. He was bleeding from the forehead." E8 proceeded to tell me to come to the dayroom. When I went to the dayroom R7 was on the floor. I told E8 not to move or touch R7. We proceeded to call E9 (Nurse), then she came to assess R7. E9 called a Code and initiated Cardio Pulmonary Resuscitation immediately. R7 was non-responsive. Surveyor asked E6 what she meant by non-responsive? E6 stated," R7 was not breathing." Surveyor asked E8 where was E9 at the time R7 fell? E6 stated," E9 was passing medication down at the other end of the hallway. E9 was not near the dayroom/dining room." Per telephone conversation with E9, E9 (nurse) stated, “I was passing meds, did not see the resident fall but did see the resident on the floor on his back with an apparent head injury." Per interview with E8 (CNA) on 07/30/03 at 3:00 p.m. in the Assistant Administrator's office, E8 stated, “There were only two CNA's. We were doing other tasks. We were unable to be in the dayroom at all times. It was after dinner about 6:30P.M.. It was myself and E6. We were alternating monitoring the dayroom. R7 is blind. I sat R7 in a regular chair in the dayroom". Surveyor asked E8 if R7 was alone in the dayroom? E8 stated," Yes, R7 was in the dayroom alone with no CNA's. After, I left another CNA (R6) came in and watched about 2 minutes, then I went back to the day room in about 10 minutes. I told E6 since the linen cart was not far from the dayroom. I would pop in and out to monitor the residents. When I looked in the dayroom at about 5:30P.M., R7 was standing up. So, I set him down in the chair. I went back separating the linen. I heard a thump on the floor. I ran to the dayroom and noted R7 on the floor. R7 was lying on the floor face down with his head turned to the side. I did not see R7 get up. I went and got E6. I told her R7 was on the floor and to help me to get him up. Before I touched R7, I observed he was bleeding from the forehead. E6 told me to go get E9. I told E9 that R7 was on the floor and bleeding from forehead. E9 was holding R7's neck while rolling him over. R7 was non-responsive. I also told E3 (Charge Nurse) what happened. E9 told E6 to call a code. R7 was not breathing. E3 and E9 started CPR." E8 stated, "R7 got up out of the chair all the time." Surveyor asked if R7 could walk alone? E8 stated, "No, you hold R7 hand to walk him. E9 was yelling at us. E9 said someone should have been in the dayroom. E9 asked us whether R7 was in a wheelchair. We told E9 that R7 was in a regular chair." Upon interview on 08/05/03, Z2 (attending physician) stated that he did not remember this resident because "he sees many residents at many nursing homes." Z2 could give surveyor no further information regarding R7's status. The care plan dated 04/09/03 for R7 states," R7 needs constant supervision at all times." The approaches were: "place R7 close to nurses station for close monitoring and supervision." Per interview with E10 (Assistant Director of Nurses) on 07/31/03 at 2:20 P.M. in the Assistant Administrator office, E10 stated, "we do not label our residents as constant supervision. We monitor every resident throughout the shift." Surveyor asked what does a care plan mean to monitor or supervise R7 constantly at all times? E10 states, "That means to monitor or supervise R7 at all times. They should be watching R7 closely throughout the each shift." The facility did not present any evidence that the staff were providing R7 with constant monitoring and supervision as indicated in the care plan at the time of the injury. Review of the facility's policy on "Safety and Supervision of Residents" addresses only resident safety during activities. E1 stated that there were no other policies regarding resident safety and supervision. |