cms_AK: 36

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
36 KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE 25010 3100 TONGASS AVENUE KETCHIKAN AK 99901 2019-08-23 909 E 0 1 0OWF11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 2 sampled residents' (#s 2 and 7) and 1 non-sampled resident's (#21) bed mattresses out of 24 residents reviewed were inspected and maintained in a safe manner to reduce the risk of improper use and entrapment. Specifically, the facility failed to ensure the mattresses were appropriately fitted in the bed frame. This failed practice place the residents at risk for entrapment and less than optimal comfort level while in bed. Findings: Resident #2 Record review from 8/19-22/19 revealed Resident #2 had a history of [REDACTED]. Review of the most recent annual Minimum Data Set (MDS - a federally required assessment), dated 8/22/19, revealed Resident #2 was coded as having severely impaired cognitive skills for daily decision making. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #7 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the admission MDS, dated [DATE], revealed Resident #7 was coded as having severely impaired cognitive skills for daily decision making, as well as having short and long term memory problems. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #21 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the most recent MDS dated [DATE], revealed Resident #21 was coded as having severely impaired cognitive skills for daily decision making; short and long term memory problems; and disorganized thinking. During random observations from 8/19-22/19 revealed Resident #21's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. During an interview on 8/23/19 at 4:19 pm Licensed Nurse (LN) #4 stated the beds were new to the long term care unit and he/she was unaware the bed mattresses for Resident #'s 2; 7; and 21 were pushed down and vertically upwards at the footboard. During an interview on 8/23/19 at 4:21 pm the Director of Nursing (DON) stated the beds recently came from the medical-surgical unit in the critical access hospital. The DON further stated the beds had adjustable footboards that allowed the length of the bed to be adjusted. When asked if the mattresses were to be pushed down and forced upwards several inches, the DON stated the beds were designed to that to prevent drop foot ([MEDICAL CONDITION] in which the dropping of the forefoot happens due to weakness, irritation or damage). The DON further stated that the biomedical technician could provide documentation regarding the beds. During an interview on 8/29/19 at 2:30 pm Biomedical Technician (BT) #1 stated the beds were [NAME]-Rom Versicare beds Model P3200/P3201 that were recently transferred to the long term care from the hospital. When asked about the mattresses curving upward at the foot of the bed, BT #1 stated he/she visualized the mattresses and stated the bed and mattress assembly were not designed to function in that manner. The BT further stated due to the adjustable feature the frame could have been set on the shortest setting which caused the mattress to be compressed and move upward. Review of the Versacare Bed User Manual for Models P3200/P3201 USR 119, revision 8 - undated, revealed The retractable foot section provides multiple patient benefits. However, a retracted foot section may increase the risk of patient entanglement between the siderails and footboard for certain patients. If a potential for entanglement exists, such as with patients who are agitated or disoriented, or who lack the physical strength to extract themselves should they become entangled, the foot section should be left fully extended when the patient is not under direct supervision. Further revealed no feature that allowed the mattress to compressed and pushed up vertically at the footboard. Review of the U.S. Food and Drug Administration publication Practice Hospital Bed Safety, dated 2/11/13, accessed at https://www.fda.gov/consumers/consumer-updates/practice-hospital-bed-safety, accessed on 9/6/19, revealed Ensure that each component-the bed frame, mattress, rails, and any added accessories-properly fits together. Make sure the mattress is the correct size for the bed frame so unsafe gaps are not present. 2020-09-01