lowa Department of Inspections and Appeals Health Facilities Division Citation Number Report date Fo#asis: March 16, 2010 | Faciityname ‘Survey dates: Belle Plaine Nursing & February 16-19, 2010 and March 2, Rehab 2010. Facility address ‘Surveyors: 1605 Sunset Drive City dsitd Belle Plaine, lowa 52208 Rule or Code Nature of Violation Giass_| Fine Correction Section Amount _| Date 58.19(2) “481—58.19(138C) Required nursing services for 7 $10,000.00 | Upon residents, The program pian for nursing facities shall Receipt have the following required nursing services under the 24-hour direction of qualified nurses with ancillary coverage as set forth in these rules: 58.19(2) Medication and treatment {Provision of accurate assessment and timely intervention for all residents who have an onset of adverse symptoms which represent a change in mental, ‘emotional, or physical condition. (Ill, Ill) DESCRIPTION: Based on record review and staff interviews the facility failed to assess a resident with a significant change in condition and provide timely interventions, Resident #1 displayed agitation and moaning and staff did not perform aan assessment for the chiange of condition before ‘administering Morphine (analgesic) at 12:20 a.m. At approximately 6:20 a.m. staff identified the resident in bed with a deformed fractured femur (thigh bone). The ‘sample consisted of 6 residents and the facllty reported a ‘census of 54 residents. Findings include: 4. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 11/7/2009, which indicated the resident had short and long term memory impairments and moderately impaired for daily decision ‘making skills. The MDS identified the resident had diagnosis of osteoporosis, dementia other than Alzheimer’s disease, arthritis, anemia, and anxiety disorder. The assessment reflected the resident could make self understood sometimes and could understand others sometimes. A documented behavioral symptom included wandering (moved with no rational purpose, seemingly oblivious to needs or safety). The MDS Page 1 of 6 Facility Administrator Date If, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (35%) pursuant to lowa Code section 135C.43A (Supp. 2009).‘acility name Rehab Bolle Plaine Nursing & lowa Department of Inspections and Appeals Health Facilities Division Citation Number FC#4315 Fe Survey dates: February 16-19, 2010 and March 2, 2010. Facility address ‘Surveyors: 1505 Sunset Drive cy ‘asitd Belle Plaine, lowa 52208 Rule or Code Section Nature of Violation Class Fine Correction Amount _| Date documented one person for physical assistance with toilet use and personal hygiene and received Hospice care. Apphysician’s progress note dated 12/14/2009 documented the June 2009 hip x-ays identified moderate to severe arthritic changes. Review of the radiology report dated 6/1/2009 documented the resident with post surgical changes in the hips bilaterally with three threaded pins seen in both hips. The appearance of the pins and positioning had unchanged from the prior study. No acute fractures, or dislocations are identified. ‘physician consult dated 1/28/2010 documented the resident received Hospice care due to failure to thrive, ‘Annurse's note dated 2/1/10 at 6:20 a.m. revealed a CNA found the resident lying in bed while assisting with activities of daily living. Continued review of the documentation stated: Resident right leg bent in wth possible hip dislocation and right arm abrasion noted. Resident unable to explain what occurred or rate pain. Continued review of the clinical record revealed no documentation of the condition ofthe resident prior to this time for the night shift of 2/1/10 or the evening shift of 118110, ‘The nurse's notes of 2/1/10 at 6:45 am. revealed staff transported the resident to the hospital by ambulance. Review of the hospital emergency department cinical report dated 2/1/10 documented in the history: Nursing home found patient in bed with bed alarm on with obvious deformity of right hip/right leg. Unknown if heishe fell or how he/she got back in bed. Femur angled. ‘The hospital physical assessment dated 2/1/10 8:00 a.m. documented a 4 om circular superficial flap-like: Page 2 of 6 Faciity Administrator Date Hf, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (35%) pursuant to lowa Code section 135C.43A (Supp. 2003).lowa Department of Inspections and Appeals Health Facilities Division Citation Report date March 16, 2010 Facility name ‘Survey dates: Belle Plaine Nursing & February 16-19, 2010 and March 2, Rehab 2010. Facility address ‘Surveyors: 1505 Sunset Drive City dsitd Belle Plaine, towa 52208 Rule or Code Nature of Violation Class | Fine Correction Section Amount _| Date Taceration to the right forearm with bright red blood ‘crusted around the wound. Review of a hospital operative report dated 2/1/2010 documented a pre and post operative report ofthe right femur fracture with the procedure completed of intramedullary rodding of the right femur fracture after hardware removal of 3 screws from the right femoral neck, ‘The nurse’s notes dated 2/4/2010 at 12:40 p.m. revealed the resident retumed to the faclty from the hospital. The staff could not perform an assessment due to the resident's agitation. At 4:00 p.m. the hospice nurse performed an assessment and noted a large bump area located on the left upper arm. An x-ray was performed at, 8:20 p.m. which identfied and a fractured upper arm, The origin of the fracture could not be determined, however, the Administrator stated the resident returned to the facility with a fractured arm and the fracture did not occur atthe facil (On 2/6/2010 at 2:20 a.m. the nurse's notes reflected the resident expited. The death certiicate identified the date of death 2s 2/5/2010 due to cardiopulmonary failure and failure to thrive. Staff Interviews: (On 2/17/2010 at 6:00 a.m. Staff A (Certified Nursing Assistant) was interviewed. Staff A identified Resident #1 ‘as very confused on the night shift of 1/31/10-2/1/10 and calling out for mom and would not sleep. Staff A stated the alarm set off 45 times. Staff A stated the resident took 1 staff person to assist usually but that night required 2 persons as directed by the night nurse. Staff A indicated the resident did not act as in pain but did moan and groan. Staff A stated the resident had loose bowel Page 3 of 6 rator Date If, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (35%) pursuant to lowa Code section 135C.43A (Supp. 2009).lowa Department of Inspections and Appeals Health Facilities Di Citation Number Fowa315 Facility name Survey date Belle Plaine Nursing & February 16. Rehab 2010. port date March 16, 2010 2010 and March 2, Facility address ‘Surveyors: 1505 Sunset Drive City asia Belle Plaine, lowa 52208 Rule of Code Nature of Violation Class] Fir Correction Section Amount _| Date ‘movements during the night and required assist with ambulating to the toilet at least 4 times during the night shift (On 2119/2010 at 8:20 a.m, Staff A stated Resident #1 sat at the desk most of the time on the night shift of 1/31/10- 2/1/10 as they had tried to lay the resident down in bed and the fall alarm would activate right way. Staff A stated the resident walked to the bathroom with 2 staff persons and walked in an unsteady manner. Staff A described the resident as sleepy and groggy. Interview with Staff B, CNA, on 2/17/10 at 2:05 p.m. revealed Resident #1 as more agitated than normal on 1/31/10-2/1/10, Staff B stated when she assisted Staff A and placed the resident on the toilet, the resident waked slower and shuffled his/her feet. Staff B indicated the resident remained agitated Interview with Staff B on 2/1910 at 9:30 am. revealed Resident #1 as unusually agitated the night of 1/31/10- 2/1/10 and the comment they could usually get the resident to lie down and rest but that night they couldn't Staff B indicated with the second interview the resident Usually took smail steps but that night the resident had shuffiing steps. Staff 8 indicated the resident could pick his/her feet up to step onto the fall mat beside the bed to get into bed. ‘On 2/17/2010 at 3:00 p.m., Staff C, LPN (Licensed Practical Nurse) was interviewed. Staff C stated while the resident sat at the nurses’ station on 1/31/10 at 10:30 pm., the resident became a litle agitated. Staff C stated it as not unusual for the resident to be agitated through the night like that. Staff C indicated at 12:10 a.m. on 2/1/2010, the resident moaned so she administered Morphine (narcotic, Page 4 of 6 Facility Administrator Date if, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (35%) pursuant to lowa Code section 135C.43A (Supp. 2009).Number Fow4315 Facility name Rehab Belle Plaine Nursing & Fobruary 16-19, 2010 and March 2, lowa Department of Inspections and Appeals Health Facilities Division Citation Report date March 46, 2010 ‘Survey dates 2010. Facility address ‘Surveyors: 1505 Sunset Drive iy Belle Plaine, lowa 52208 ‘dsitd Rule or Code Section Nature of Violation Cass Correction Amount _| Date ‘analgesic) to the resident. Staff C continued fo say the ‘Ativan (antianxiety medication) given the day before had been ineffective. And the Morphine calmed the resident. Staff C indicated the resident rested in bed until 1:45 a.m. (on 2/1/10 and then the resident came back to the nurse's. station. Staff C stated they gave the resident a snack and the resident took off hisiher slippers and touched histher toes. Staff C stated no one left the resident unattended at the nurse's station. Staff C stated she asked Staff A & B to lay the resident down at 3:45 a.m, and with the next medication pass (administration of medications) at approximately 5:15 - 6:30 a.m. on 2/1/10 they looked through the resident's open door and the resident laid in bed and in no distress and no bed elarm sounded. On 2/22/10 at 4:33. am., Staff C revealed she gave instruction to Staff A and B on the night shift of 1/31/10 - 2/1/10 for 2 people to be with the resident due to Unstable. By unstable Staff C clarified the resident needed more cares and the resident unstable on his/her feet as Staff C had given the resident Morphine a litle after midnight on 2/1/10 because the resident moaned, Staff C stated the resident could not verbalize the cause of the moaning and this as not unusual. Staff C indicated when a person works with a resident day in and day out, she could tell when the resident would need a litle more help than on another day. Staff C indicated her assessment consisted of the resident resting and quiet after the administration of Morphine. Staff C was questioned about the detail of the assessment and staff C stated “I looked at her/him”. ‘The medical examiner investigator was interviewed at 12:25 p.m. on 2/19/2010. The investigator stated he found this unusual with this severe of a fracture and no Page 5 of 6 Facility Administrator Date If, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (35%) pursuant to lowa Code section 135C.43A (Supp. 2009),lowa Department of Inspections and Appeals Health Facilities Division Citation Facility name ‘Survey date: Belle Plaine Nursing & February 16-19, 2010 and March 2, Rehab 2010. Facility address ‘Surveyors: 1505 Sunset Drive City asia Belle Plaine, lowa 52208 Rule or Code Nature of Violation Class] Fine Correction Section Amount _| Date mechanism of injury. He further stated staff had told they found the resident with this injury and this fracture Could not have been spontaneous and had to be a blow or a fairly significant fall The orthopedic surgeon was interviewed on 2/17/2010 at 8:55 am. and stated trauma would have occurred to cause this fracture. The surgeon voiced this fracture could not have occurred while the resident just laid in bed and the fracture would have had to ocour with force, a fal or twisting of the leg, FACILITY RESPONSE: Page 6 of 6 Facility Administrator Dats Hf, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty-five percent (88%) pursuant to lowa Code section 135C.43A (Supp. 2009).