Madison Post Acute
MADISON POST ACUTE in EVERETT, WA — inspection on August 7, 2024.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F655 - Baseline Care Plan
CFR 483.21(b), (b)(1),(c)(3)(i - iv),
F-F656 - Develop/implement Comprehensive Care Plan
CFR 483.21(b),(b)(2)(i-iii),
Findings included .
Resident 13 readmitted to the facility on [DATE] with diagnoses to include fall, high blood pressure, fracture of right upper leg.
In an interview and observation on 07/31/2024 at 2:54 PM, Resident 13 stated they had fallen out of their bed around eight months ago. Resident 13 stated they had been asleep in their bed when they had moved the bed control and started to fall over to the right side and fell from their bed.
During the observation a blue foam wedge was noted at the foot of Resident 13's bed.
Review the incident report, dated 01/02/2024, showed that Resident 13 sustained a fall at 2:45 AM and was assisted back to bed after they refused to be sent to the hospital.
The incident report showed Resident 13 voiced being disproportionate in their hip and legs which had them leaning to the right side which led to the fall while they were asleep. Resident 13's care plan was updated.
The incident summary dated 01/05/2024, showed therapy assessed Resident 13 and determined the cause of the fall was related to their poor trunk control. Resident 13 was assessed by therapy, and they recommended a positioning wedge be placed under the resident's right hip/leg and secured with a strap that is attached to the bed frame.
In a follow up interview and observation on 08/07/2024 at 11:15 AM, Resident 13 stated the blue wedge was to assist them in not falling out of bed. Resident 13 was observed to use their cane to pull the blue wedge from the foot of their bed to them and positioned it under their right hip/leg.
There was no strap observed on the wedge. Resident 13 stated the wedge worked well as an arm rest. Resident 13 stated they had not used the wedge the night before and required no reminders from staff to use it.
Review of Resident 13's care plan dated 01/04/2024 and revised 06/12/2024 showed they were at high risk for falls and they had a positioning wedge with secure strap for safety and comfort to be positioned on their right side (hip/leg).
The care plan directed staff to notify the nurse if the wedge was not secured and to unstrap the wedge while Resident 13 was awake and per their request.
There was no information in the care plan that addressed Resident 13's poor trunk control.
Review of Resident 13's treatment administration record for July 2024 showed no information about the use of the positioning wedge.
505463
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505463 B.
Wing 08/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Madison Post Acute 2520 Madison Everett, WA 98203