prevention

Many problems in this article need to be addressed which has been copied and pasted below. The are concerns that are recognizable regarding the patient, staff and agency. There are some resources as well to set up a method to address the issue and give recommendations.



Due to at copy and paste method the article was unable to paste appropriately. However you can pull it up online at www.ChicoEr.com

Chico nursing home fined $100,000
A nursing: home has been
- ordered to pay a $100,O00 in connection
with -the death of an elder resident.

Jason Smith, a spokesman for Evergreen
,> Hedthcare Management.the Department of
Public Health.
The patient who died, 98-year old resident, slipped out of her wheelchair. She was stranggled by a belt that was suppose to keep her in the chair. She was diagnosed with
Alzheimer's, anxiety, depression, weakness and psychosis,
according to state documents.
Often, she would slip down in her wheelchair. Staff
members had to watch her and pull her up when that happened,
the documents said. For a time, a device called a
pummel cushion was used to help keep her in the chair,
but for some reason its use was discontinued. A restraint
called a "soft waist belt" wa3 used to help prevent her
from falling out of the chair.
During supper on Dec. 7, the woman kept sliding
down in her wheelchair. It happened so many times that
two certified nurse assistants (CNAs) who were working
in the dining room decided to put her to bed immediately,
documents stated.
The two CNAs, who weren't regular staff members but
had been hired through a registry to work temporarily,
were taking the woman to her room when they were
stopped by a family member of another resident, who
asked them to put that resident to bed first.
According to documents, the two CNAs said they
thought the woman in the wheelchair would be all right
by herself for a little while, so they left her in the doorway
of her room and attended to the other resident.
Twenty to 30 minutes later, the documents said, the
two CNAs came out into the hall and noticed that the
door was closed to the room of the woman in the wheelchair.
They opened the door and saw the woman on the
floor with the waist belt pressed against her neck and
chest, the documents stated. She wasn't breathing.
The nurse assistants began performing CPR, but a
nurse who had been called told them to stop because the
woman had left instructions that she was not to be resuscitated,
the documents said..
Twin Oaks reported the incident to the Department of
Public Health, which investigated. The nursing home was
issued a Class AA citation for failing to keep the resident
safe and not providing adequate supervision.
Class AA citations are the most serious the state
issues. They carry a fine of between $25,000 and
$loo,ooo.
The nursing home was required to develop what's
called a plan of correction. In its plan, the 'kin Oaks
administration said the entire staff, including employees
hired through registries, would be instructed that residents' safety must take priority over all other concerns.
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