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“The facility still failed to provide increased supervision.”

OWENSBORO CENTER

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

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One Response to ““The facility still failed to provide increased supervision.””

  1. vivian middleton says:

    This is completely avoidable. We now have ALARM PAD’S that can easily be placed under a patient while in bed as well as ALARMS for those sitting up in chair’s. This is NOT CONSIDERED A RESTRAINED. The bigger problem here is that KNOW ONE CARED. All of this could have been avoided by the use of these types of alarms or at least perhaps prevented some of these fall’s. But, then of course, one has to TAKE THEM SERIOUSLY AND ACTUALLY GO CHECK ON THE PATIENT ONCE THE ALARM GOES OFF. I wonder if this facility had invested in any such devices? Such a Sad, Sad, group of incidents to occur. Our elderly are someone’s Mother,Wife, Sister, Brother. They lived a long life prior to ending up under the care of strange individual’s who know they are going home to their loved one’s once they go when their shift is over. I keep hearing how over worked they are, Understaffed they are, Under payed they are, and the list goes on. Either file a complaint against the facility and find a new job or stop complaining. Your not the one SUFFERING.

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