LOCATED: 1205 LEITCHFIELD ROAD, OWENSBORO, KY 42303
OWENSBORO 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 MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review and review of the facility’s policy it was determined the failed to have an effective system to ensure each resident receives adequate supervision to prevent accidents for one (1) of four (4) sampled residents (Resident #1).
The facility care planned Resident #1 on 05/12/15, to remind him/her to use the call light when attempting to ambulate or transfer. However, the facility had assessed Resident #1’s cognition on 05/12/15 as severely impaired. On 08/26/15, Resident #1 sustained a fall in the bathroom after getting up without using the call light when attempting to ambulate. This fall resulted in a compression fracture of the lower lumbar vertebral; the resident had to wear a back brace for approximately two (2) months. On 09/08/15, the facility identified and care planned that the resident was continuing to get up without using the call light to ask for assistance. However, the facility failed to provide increased supervision to ensure staff would be aware if the resident attempted to get up without assistance in his/her room.
On 12/05/15, Resident #1 sustained another fall in the bathroom when he/she ambulated to the bathroom without staff assistance or knowledge. This fall resulted in the resident being hospitalized with a non-displaced left femoral head fracture which required surgical intervention. The facility still failed to provide increased supervision to ensure staff would be aware if the resident attempted an unassisted transfer in his/her room.
Interview with the Assistant Director of Nursing (ADON), on 01/13/16 at 3:00 PM, revealed she knew Resident #1 was cognitively unable to learn to use the call light, or to remember to ask for help when getting out of bed. She stated she was aware Resident #1 was at high risk for falls and she expected staff to monitor the resident closely every time they passed by the room as well as conducting routine continence checks and toileting every two (2) hours. She stated the facility no longer used bed or chair alarms.
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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