cms_AZ: 5533

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

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
5533 THE TERRACES OF PHOENIX 35003 7550 NORTH 16TH STREET PHOENIX AZ 85020 2013-03-13 282 D 0 1 718011 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that the falls plan of care was implemented for two residents (#s 17 and 117). Findings include: Resident #17 was admitted to the facility on [DATE]. Review of falls care plan dated November 14, 2012, revealed the following interventions: analyze previous falls to determine whether pattern/trend can be identified; document findings and dates of review; assure that assistive devices are placed appropriately in the room when not in use; assure that commonly used items are within easy reach for the resident; assure that the resident is able to use assistive devices correctly, bed in lowest position when the resident is in bed; complete Falls Risk assessment quarterly and after each fall event; compare score to previous findings; encourage the use of hand rails, grab bars when attempting to stand; report and document all falls; use bed and wheelchair alarm to alert the staff that the resident is getting out of bed or wheelchair; the resident to wear proper non-slip footwear when out of bed; and, to administer medications as ordered. Review of the Nurse's Notes dated March 6, 2013, revealed that the resident was found on the floor laying next to her bed with her wheel chair at her feet. It was noted that the resident did not have an alarm on her wheel chair at the time of the fall per her care plan. The housekeeper who found her on the floor reported that no alarm was going off when she entered the room. Review of the clinical record revealed no documented evidence that a Falls Risk Assessment was done per the resident's care plan after a fall on March 6, 2013. An interview was conducted on March 13, 2013, with a licensed practical nurse (LPN). The LPN stated that she does not know why the care plan was not followed for this resident. An interview was conducted on March 14, 2013, with the director of nursing (DON). The DON stated that the care plan should have been followed by the staff. -Resident #117, was admitted to the facility October 26, 2012. A Review of the Nursing Admission assessment dated [DATE], included that the resident's fall risk score was nine and at risk for falls. A review of the electronic Progress Notes dated February 5, 2013, included that the resident had experienced a fall, and was found sitting on the floor mat at his bedside. Further review of the electronic Progress Notes dated February 17, 2013, and February 18, 2013, revealed that the resident had experienced another fall and was found laying on the floor next to his bed. A Weekly Progress Summary dated February 19, 2013, included that the resident had experienced a fall on February 17, 2013, and that the care plan had been reviewed and updated if needed. A review of the resident's care plan revealed that that a care plan was initiated October 26, 2012, and that the resident was identified as being at risk for or had a history of [REDACTED]. Interventions initiated November 11, 2012, included that a falls risk assessment would be completed quarterly and after each fall event, and that behaviors and factors that affected the risk for falls would be identified. A review of the clinical record revealed that the care plan had not been implemented for the resident, as evidenced by no documented evidence that a fall risk assessment had been conducted for the resident after each fall, and quarterly. During an interview conducted March 13, 2013, the DON stated that a fall risk assessment had not been conducted quarterly or after each resident fall. Review of a facility policy titled Falls and Fall Risk, Managing, included that relevant interventions would be identified and implemented to try to minimize serious consequences of falling. 2016-09-01