Deficiency in Person-Centered Care and Documentation for Fall Interventions
Summary
The facility failed to provide person-centered care by not adequately documenting and managing the use of one-on-one sitters for residents who had experienced falls. Resident #75 had a Health Team Aide (HTA) providing one-on-one care 24 hours a day since a fall on 09/18/23, yet there was no physician's order for this intervention, and it was not included in the resident's care plan for falls. The Director of Nursing (DON) acknowledged that the Interdisciplinary Team (IDT) determines the appropriateness of one-on-one sitters without a physician's order and without documenting the review process. Additionally, the facility's Social Worker did not routinely assess the psychosocial well-being of residents receiving one-on-one sitters, and there was no documentation of such an assessment for Resident #75. Similarly, Resident #47 was observed with a staff member sitting with her after a fall on 05/03/24, which resulted in a black eye and other minor injuries. Despite the use of a one-on-one sitter as an intervention, this was not documented in the resident's care plan. The DON confirmed that the IDT had not yet met to discuss the fall or the continued use of the one-on-one sitter for Resident #47. The lack of documentation and formal assessment of the need for one-on-one sitters indicates a deficiency in the facility's approach to individualized resident care and safety management.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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