March 3, 2020 IDR Committee Notes

IDR 3-3-20

F689 D Environment Kept Free of Accident Hazards.

Per committee discussion. Alert and oriented resident was evaluated by OT to need a Hoyer lift for transfers with two staff assisting. Hoyer lift was not used at all times, resident had increase in pain, clavicle fx. was diagnosed, likely related to improper transfers without Hoyer.  Sustained

F867 H Quality Assurance Performance Improvement

Per discussion the facility failed to address several quality areas that needed improvement and were also cited during the survey such as weight loss, nutritional assessments and timely reporting of lab results. Although requested by the survey team the facility could not produce sign in sheets for Nov and Dec QAPI meetings.  Sustained

F 604 G  (Changed to F600 following committee discussion)  Residents have the right to be treated with dignity and respect.

Per discussion resident with MS was care planned to need assit when transferring. Resident transferred self from bed to power wc. Facility took power wc away from resident stating that it was a safety issue for resident. Resident stated he/she felt punished. Following committee discussion that taking the power wc from resident was a type of confinement, the deficiency was moved to F 600 and lowered to “D”.    Sustained at    F600 D Freedom from Abuse and Neglect

F 600 G Freedom from Abuse and Neglect

Resident that required BiPAP at night and oxygen @ 2 L twenty-four hours a day had BiPAP placed by CNA and not checked by nurse. It appeared that the BiPAP was not placed properly with O2 flowing and resident had a negative outcome. Sustained at G

F695 J Respiratory Care Services

Facility policy called for nurse to place BiPAP machines. CNA placed BiPAP on resident at night and had negative outcome as O2 was not flowing properly. Following this incident facility could not show education and policy review to ensure appropriately trained staff were placing BiPAP machines. Sustained

F 697 G  Pain Management

Resident had a fall, was transferred from floor to bed, after appropriate assessment. Following fall resident complained of increased pain, additional assessment was not completed and following several reports of increasing pain fx was diagnosed. Sustained