Willow Woods Rehabilitation And Nursing

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unassisted seating or transportation for long distances/periods.- Fall Prevention: The warning labels on the equipment specifically state: To prevent falls, never leave the patient unattended in the Sara Steady.Patient Participation: The device is intended for use by residents who can bear some weight on at least one leg, have some upper body strength, and can actively participate in the standing process by pulling themselves up with the support of the handlebars.- Caregiver Training: Use of the equipment requires a caregiver trained in following the instructions for use and in assessing the resident's condition and capabilities before each use.- Failing to follow these guidelines could result in serious injury or falls for the resident. The deficient practice was corrected on [DATE REDACTED] when the facility implemented the following corrective actions: - On [DATE REDACTED] at 7:20 P.M. LPN #524 notified Resident #62's son of the transport to the hospital. He reported that he had just spoken to the hospital.- On [DATE REDACTED] at 7:30 P.M. LPN #524 notified Medical Director #578 of Resident #62's transfer to the hospital.- On [DATE REDACTED] at 8:19 P.M. CNA #567 was suspended pending investigation.- On [DATE REDACTED], all staff were immediately educated by the DON on transfer assistance, supervision of residents. Call light availability, mechanical lift usage, change in condition, dignity, and facility abuse and neglect policy.- On [DATE REDACTED] at 9:00 am-9:30 A.M. the DON reviewed the clinical documentation for the past 72 hours to ensure all changes in condition were addressed.- On [DATE REDACTED] from 10:30 A.M. to 10:55 A.M. an Ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant Director of Nursing (ADON) #576, Medical Director #578, Activities Director #557, Staffing Coordinator #561, Business Office Manager #503, Human Resources (HR) Director #545, Wound RN #528, Social Services Director (SSD) #514. The root cause analysis was reviewed and corrective action taken. The Administrator educated those in attendance on transfer assistance, supervision of residents, call light availability, mechanical lift usage, change in condition, dignity and facility abuse and neglect policy.- On [DATE REDACTED], Activity Director #557 and Wound RN #528 completed interviews of all residents with a BIMS greater than 12 and assessments of all residents with a BIMS score of 12 or lower to ensure freedom of abuse, neglect, and misappropriation. - On [DATE REDACTED],

the DON and ADON #576 reviewed and updated transfer status orders for all residents, reviewed and updated care plans as necessary for transfer status for all residents, and reviewed and updated Kardex and Point of Care tasks as necessary for transfer status for all residents.- On [DATE REDACTED] from 10:56 A.M. to 11:45 A.M. SSD #514 completed an observational audit to ensure all residents' call lights were within reach in room and residents were treated with dignity and respect.- On [DATE REDACTED], the DON completed an audit to ensure all nurses had valid CPR training. - On [DATE REDACTED], competencies were initiated by Regional Director of Clinical [NAME] #577 and CNA Supervisor #561to ensure all nursing staff is competent utilizing lifts.

Competencies will be completed prior to the next scheduled shift. - Beginning [DATE REDACTED] the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure no abuse/neglect allegations and that call lights are within reach through [DATE REDACTED].- Beginning [DATE REDACTED], the DON/designee will complete an audit of documentation for change

in condition an new admissions to ensure appropriate care planning, orders, assessments and interventions for resident transfer status five times a week for four weeks and randomly thereafter though [DATE REDACTED].- Beginning on [DATE REDACTED], the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure residents are being transferred appropriately through [DATE REDACTED]. This deficiency represents noncompliance investigated under Master Complaint Number 2667747 and Complaint Number 2667167.

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