WARREN MANOR HEALTH AND REHABILITATION CENTER
LOCATED: 11 BELL ROAD, SELMA, AL 36701
WARREN MANOR HEALTH AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews, record reviews and review of a facility policy titled, Fall Management, the facility failed to assess Resident Identifier (RI) #1 and RI #5’s neurological status, as directed in the policy, after both residents sustained a fall with injuries.
RI #1 fell on [DATE], and sustained an injury to the forehead. The assigned nurse indicated she did not follow the facility’s Policy and Procedure for Fall Management for residents with potential head injuries. RI #1 was sent out to the emergency room (ER) and the Computed Tomography (CT) revealed C1 (first cervical vertebrae) and C2 (second cervical vertebrae) neck fractures.
On 08/16/2016, at 2:15 p.m., the surveyor conducted an interview with EI #4, the Registered Nurse (RN) assigned to care for RI #1 on 07/24/2016, on the 3p-11p shift. The surveyor asked EI #4 did she observe RI #1 on the floor on 07/24/2016. EI #4 said she did. EI #4 said RI #1 was on a blue mat on the floor laying on his/her left side. The surveyor asked EI #4 what the facility ‘ s policy instructed her to do after finding a resident on the floor. EI #4 replied, to assess them, assist them back to bed. The surveyor asked EI #4 what she did after RI #1 was found on the floor. EI #4 said she asked the Certified Nursing Assistant (CNA) was there any reason RI #1 was on the floor. EI #4 said RI #1 had a scratch on his/her forehead and put triple antibiotic ointment on it. The surveyor asked EI #4 what type assessment did she perform on RI #1. EI #4 said she looked at RI #1 and saw that RI #1’s right eye was opened. EI #4 said she asked the CNAs to put RI #1 back to bed and went to get a tab monitor. The surveyor asked EI #4 did she ask RI #1 anything while RI #1 was on the floor. EI #4 said when she realized who RI #1 was she realized RI#1 would not be able to tell her if (he/she) was hurting. The surveyor asked EI #4 what type of assessment is done when a resident is found on the floor. EI #4 said you had to make sure the resident is awake and alert. EI #4 said she did not know about the facility’s policy but you would make sure the resident did not have any injuries, do vitals, and notify the family and physician. The surveyor asked EI #4 was RI #1 moving (his/her) extremities while on the floor. EI #4 replied, No, (he/she) was just lying there The surveyor asked EI #4 did she attempt to move RI #1’s extremities. EI #4 said, No I didn’t. The surveyor asked EI #4 did she palpate RI #1’s head. EI #4 said no. The surveyor asked EI #4 were neuro checks done. EI #4 replied, not that day. EI #4 was asked to review the Fall Management Policy and then was asked about the neurological assessment. EI #4 said a copy of the
Neurological Assessment form was at the nurse’s station. EI #4 went to the nurse ‘ s station and retrieved a copy of the Neurological Record, where the Neurological assessment findings are documented, was presented it to the surveyor for review. The surveyor asked EI #4 was the Neurological assess completed when a resident falls. EI #4 said if the resident was going to stay in the facility after a head injury then the Neurological assessment is completed. The surveyor asked EI #4 did she do level of conscious checks on RI #1. EI #4 replied, I didn’t do pupil checks. I didn’t do motor skill checks. I didn’t do the form (Neurological Record) because we sent (him/her) out. The surveyor asked EI #4 about how long was it before RI #1 was sent out of the facility. EI #4 said about 30-35 minutes.
A review of the Incident/Accident Report completed by EI #4, revealed RI #1 was transferred out of the facility at 5:05 p.m. On 08/18/2016 at 12:05 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2, what she expected her staff to do when a resident is observed on the floor. EI #2 replied, I expect the staff to assess the resident. The surveyor asked EI #2 what type assessment she would expect the nurse to perform. EI #2 said if the resident was alert the nurse would ask questions like if they are ok, in pain, and what happened (cause of the fall). EI #2 said the nurse would move the resident’s extremities and usually feel the head, legs and palpate for any abnormalities. The surveyor asked EI #2 where the assessments would be performed. EI #2 said if the resident is found on the floor, then the assessment would be done on the resident while he/she is on the floor depending on the severity.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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