cms_SD: 183
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 183 | AVANTARA NORTON | 435039 | 3600 SOUTH NORTON AVENUE | SIOUX FALLS | SD | 57105 | 2019-10-17 | 610 | E | 0 | 1 | SJ6G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, policy and procedure review, the provider failed to ensure a thorough investigation had been completed and documented for two of two sampled residents (34 and 73) who had a fall with injury. Findings include: 1. Review of resident 73's medical record revealed: *admission date of [DATE]. *She had been admitted on Medicare part A/skilled nursing. *She had been receiving occupational therapy (OT) and physical therapy (PT) services with a goal to return home. *The undated Admission Observations flow sheet stated she required assist of 2 with transfers. Review of the admission 9/5/19 Minimum Data Set (MDS) assessment for resident 73 revealed: *A Brief Interview for Mental Status assessment score of fourteen indicating she was cognitive. *She required: -Extensive assistance of two staff members with transfer and toilet use. -Limited assistance of one staff member with ambulation. Interview on 10/16/19 at 4:03 p.m. with resident 73 revealed: *She had gone to the hospital on [DATE] from her own home, because she woke up and could not walk. *They sent her to the nursing home around 9/1/19 for occupational therapy and physical therapy. *On 9/14/19 a staff member had been assisting her to the bathroom. -They had placed a gait belt on her and were assisting her with the walker. -The staff member let go of her, walked around her, and opened the bathroom door. -She fell backwards to the floor hitting the back of her head. -They sent her to the hospital. -She ended up with a bump to the back of her head and had broken her right collar bone. -She would be resuming therapy services on 10/23/19. Continued interview on 10/17/19 at 10:30 a.m. with resident 73 regarding her fall on 9/14/19 revealed the same story as she had said above. Review of the South Dakota Department of Health required healthcare facility event reporting final report for resident 73 revealed:*Cognition score of fourteen indicating she was cognitive. *Brief explanation of the above event being reported was: -Resident had a fall on 9/14/19 at 1000 (10:00 a.m.). -She stated she hit her head on her built in dresser as she fell backwards. -Has a bump to the back of her head. -Right clavicle was pushed forward. -Vitals stable and neuros (neurology signs) within normal limits. -MD (medical doctor) notified of bump to head and clavicle disposition and ordered to send to ER (emergency room ) for evaluation. -Family notified and (resident name) sent via ambulance to the ER. *Conclusionary summary of facility investigation for the above: - Allegation of abuse/neglect unsubstantiated. -X-ray to clavicle shows that R (right) clavicle is fractured. -Fall was witnessed by RN (registered nurse). -It appears that (resident name) lost her balance while walking into the bathroom. -Therapy notified to see if any other evaluations needed for treatment due to balance. -Care plan and pocket care plan updated to have supervision to 1 assist with ADL's (activities of daily living) and walking related to balance. Review of the facility's 9/14/19 Fall Report for resident 73 revealed:*Time of fall was 10:00 a.m. *The fall had occurred in her room. *It had been witnessed by RN U. *RN U had documented:-RN assisting resident to bathroom for BM (bowel movement) when she lost her balance and fell backwards into wardrobe. Large hematoma noted immediately to back. -Resident interview: I just lost my balance. Just my head hurts. (Later stated pain to clavicle). *Nursing assessment regarding the cause for the fall and interventions: -Resident lost balance. Review of the 9/13/19 and 9/14/19 interdisciplinary progress notes for resident 73 with the following dates revealed on: *9/13/19 at 2:40 p.m.: -In PT she is walking 100 feet and stairs. -Plan is to continue to strengthen the leg, work on balance and stairs, dressing and toileting. *9/14/19 at: -5:26 p.m.: Writer was helping resident to restroom in her room when she fell backwards and hit her head on the wardrobe. --Writer had just gotten pt (resident) up from recliner using gait belt and FWW (front wheel walker). --Resident was standing and lost her balance tripping backwards. -5:29 p.m.: X-ray to clavicle shows that R clavicle is fractured. Review of the 9/12/19 through 9/19/19 OT notes for resident 73 revealed on: *9/12/19: -Goal: toileting:--Current level of function: Completes toilet transfers with CGA (contact guard assist), toileting tasks requiring minimal assistance. Goal date 9/26/19. -Goal: Activity tolerance while standing:--Maintains functional standing postural alignment and balance for 7 minutes, limited primarily by a deficit in standing balance self cares at stand with minimum assistance. Goal date 9/26/19. -Remaining functional deficits/underlying impairments: --Patient has the following remaining impairments impacting function: standing balance, activity tolerance, safety with 4WW. -Precautions: Chronic R knee pain, low back pain, fall risk. *9/19/19: -Goal: Activity tolerance while standing: --Maintains functional standing postural alignment and balance for 4 minutes, limited primarily by a deficit in standing balance, impacting ability to complete selfcare at stand with minimum assistance. Goal date 9/26/19. Review of the 9/13/19 through 10/1/19 PT notes for resident 73 revealed on: *9/13/19: -Impact on burden of care/daily life: --Patient continues to be at high risk for falls with needing CGA for sit to stand and surface to surface with walker with CGA with ambulation. -Precautions: --Balance precautions include fall risk, chronic low back and R knee pain. *9/20/19: -Other notations: --Patient has had a decline in function this week as she had a fall this week hitting her head and fx (fracture) R clavicle, is now non weight bearing RUE (right upper extremity) and wearing sling RUE. *10/1/19: -Impact on burden of care/daily life: --Nursing reports patient is now able to participate with TRANSFERS WITH CGA in room. Review of the 9/14/19 emergency department report for resident 73 revealed a [DIAGNOSES REDACTED]. Review of the updated care plan for resident 73 with the following dates revealed: *9/10/19: -Problem: At risk for falls related to weakness, decreased mobility, and right knee and back pain. -Interventions: --Will receive assistance with transfers to reduce the risk of falls. --Will receive assistance with locomotion. --Will receive assistance walking to reduce the risk of falls. --Mobility devices/equipment FWW and w/c. -Problem: Activities of Daily Living: -Interventions: --Resident transfers with assist of one and uses a FWW. --Use gait belt for all transfers. --Provide assist of one for personal hygiene. Interview on 10/17/19 at 2:00 p.m. with the administrator and the director of nursing (DON) regarding resident 73's fall on 9/14/19 revealed: *They had relied on the nurses for the fall reports. *The nurse who had been assisting her during the fall was RN U. -She was a new nurse. -She had been employed less than a month. *They had not asked the resident what had happened during the investigation. *They agreed the resident was cognitive. -They should have asked the resident during their internal investigation what had happened *They agreed the two stories had not collaborated. *The fall had impacted the resident's therapy. *They had not done a thorough internal investigation of the resident's fall. 2. Review of resident 34's medical record revealed: *He was admitted on [DATE]. *His Brief Interview for Mental Status assessment score was thirteen indicating he was cognitively intact. *He had a [DIAGNOSES REDACTED]. *Her required one assist with a pivot transfer. *On 6/14/19 he had a fall resulting in a [MEDICAL CONDITION] and was transferred to the emergency room . Interview on 10/16/19 at 5:00 p.m. with resident 34 revealed: *He was alert and oriented to person, place, and time. *He could communicate his needs without difficulty. *There were times when staff made him angry because of their tone of voice when they came to help him. -They would say What do you want?, and he did not like that approach. Review of resident 34's 9/14/19 fall investigation revealed: *Brief explanation: The writer was notified that (resident's name) was found on the floor on 9/14/19 at 2030 (8:30 p.m.) between his wheelchair and his bed on his left side with a laceration to the left side of his head. Pressure applied to laceration, vitals obtained and stable and neuros within normal limits. -Resident was sent to the emergency room for an evaluation. *A hand-written note by the certified nursing assistant that found him with a first name only read: It was 8:15 When one was taking the laundry when one saw (resident's name) right at the door on the floor. And blood was coming from his head. When one ask him what he was doing he told me that someone make him so bad from yesterday till today so he was trying to get up to meet with the person he fell . *Conclusionary summary: Allegation of abuse/neglect unsubstantiated. -It was signed by the administrator. *There was no further evaluation of: -Who was he wanting to meet with? -Why had he not asked for assistance? -Was it a staff person who had upset him? Interview on 10/17/19 at 2:22 p.m. with the DON revealed regarding resident 34's above fall investigation revealed: *She and the administrator were responsible for making sure investigations were completed thoroughly. *She confirmed that investigation had not been thoroughly completed, because there were unanswered questions about what had upset him leading to a self-transfer and fall. Interview on 10/17/19 at 2:30 p.m. with the administrator regarding resident 34's above fall investigation revealed she: *Had reviewed that fall investigation. *Could not address what or who had upset the resident, particularly if it had been a staff person. *Confirmed that investigation had unanswered questions and had not been completed thoroughly. 3. Review of the provider's 11/28/17 Abuse and Neglect policy revealed: *Investigation: Have procedures to: -Investigate all allegations of abuse, neglect, exploitation, and misappropriation of property. -Identify staff responsible for investigation. All allegations will be investigated by the Administrator or Designee immediately. -Interview all involved person including victim, perpetrator, witnesses, and other who might have knowledge of the allegation. -Thorough documentation of the infestation. Surveyor Review of the provider's (MONTH) 2019 Falls - Clinical Protocol policy revealed: 5. The staff will evaluate and document falls that occur while the individual is in the facility. Review of the provider's (MONTH) 2019 Assessing Falls and Their Causes procedure revealed: *The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. *2. Defining Details of Falls: -a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. | 2020-09-01 |