Cliveden Nursing And Rehabilitation Center
Based on hospital documentation, facility policies/procedures and interviews with facility staff, it was determined that the nursing home failed to consistently monitor and assess a resident after a fall with a head injury and administer medications appropriately for Resident CL1. Those findings included the following: A review of Resident’s CL1 Admission Nursing note revealed that the resident was admitted after a fractured hip repair at a local Acute Care Hospital. Resident CL1’s past medical history included a history of multiple falls, and a medical condition, which affects the liver and decreases the ability to remove toxins from the body. According to the nursing notes on the day of admission the resident was identified as combative, grimacing and screaming during the initial assessment that required 1:1 monitoring for agitation and restlessness.
Resident CL1 was identified as a high fall risk and had 5 falls between February 13, 2014 and February 23, 2014. A second fall on February 23, 2014 resulted in a gash over her left eyebrow. A review of the nursing home’s policy related to Neurological Assessments that was last updated on July 2009 on April 4, 2014, revealed that a neurological assessment should be completed after a resident strikes their head every 15 minutes for an hour, every 30 minutes for 4 hours, every 1 hour for 4 hours and every 4 hours for the next 48 hours. A review of the facility’s documentation related to the Neurological Assessments, which were last updated in July of 2009 on April 4, 2014, revealed that a neurological assessment should be completed after a resident strikes their head every 15 minutes for an hour, every 30 minutes for 4 hours, every 1 hour for 4 hours and every 4 hours for the next 48 hours.
A review of the facility’s documentation related to the Neurological Assessments revealed that they were not done according to the facility’s policy. A review of a nursing note dated February 25, 2014 at 10:42 a.m. revealed that the resident was found with open fixed eyes and pinpoint pupils and was sent to the emergency room. A telephone interview with the administrator on April 4, 2014 at 11:00 a.m. confirmed that the facility did not complete the Neurological Assessment as per the facility’s policy. Further review of Resident’s CL1’s clinical record revealed that the resident was eating and drinking very little, a nursing note on February 24, 2014 at 10:42 p.m. identified her oral intake as 10% with only a few sips of liquids. Another nursing note on February 24, at 10:08 p.m. identified Resident CL1’s oral intake as 0% throughout shift with only minimal liquids. A review of the medical administration records for Resident CL1 after her fall and head injury on February 23, 2014 at 8:55 p.m. revealed that the resident received a narcotic pain medication Patch 50 micrograms per hour once on February 24, 2014 and a anti-anxiety medication 1 milligram and a mix of Tylenol. PRN and Klonopin 1mg. three more times, prior to being sent to the emergency room. A review of the emergency room initial assessment by the physician, dated February 25, 2014 at 5:00 p.m., revealed that the resident arrived unresponsive with pinpoint pupils and required intravenous fluids.