THE SPRINGS, A GRACE LIVING CENTER COMMUNITY
LOCATED: 5800 WEST OKMULGEE, MUSKOGEE, OK 74401
THE SPRINGS, A GRACE LIVING CENTER COMMUNITY 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 MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for one (#3) of three sampled residents who were reviewed for falls. The facility failed to consistently identify and implement interventions to aid in the prevention of falls for resident #3. Resident #3 had a history of [REDACTED]. The resident had four head injuries, an elbow fracture, and multiple skin tears.
The facility identified 34 residents with falls in the last three months.
On 06/21/17 at 10:05 a.m., the resident’s wife stated the resident fell and hit his head three days ago and was sent to the hospital. The resident’s wife stated she was told the resident was put on one on one. The resident’s wife stated she did not know what one on one was and had gone into the hall to ask staff what one on one was. The resident’s wife stated she had asked licensed practical nurse (LPN) #1 about the one on one when she was leaving the facility on 06/20/17. The resident’s wife stated the LPN did not know anything about the one on one. The resident’s wife stated the LPN said, If it’s not posted around here then no one knows. The resident’s wife stated no staff was in the room with the resident when she left the facility. The resident’s wife stated at least two times in the last week she had used the call light and staff had not answered. The resident’s wife stated she had gone to the nurse station and could not find staff. The resident’s wife stated she was told staff was assisting residents on other halls. The resident’s wife stated she felt the facility was short staffed. The resident’s wife stated staff was always busy and would come by the door two or three times and say they would be back in a minute. The resident’s wife stated she hoped no more falls occurred.
On 06/21/17 at 9:58 a.m., the DON stated the staff assigned to one on one for the resident was not included in the staffing schedule. The DON stated one on one meant someone would be with the resident at all times. The DON was asked who was with the resident when the one on one sitter left early during her shift. The DON stated no one. The DON was asked which CNA was assigned to the 300 hall and she stated one CNA was assigned to cover the 300 and 400 halls. The DON stated an LPN was assigned to the residents on the 300 hall. The resident roster documented 56 residents resided on the two halls which included the resident requiring a one on one sitter. No other staff was called in to cover for the CNA who left early during their shift. The charge nurse stated she felt they had sufficient staff to cover both halls and the one on one resident.
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.