cms_DE: 65

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
65 WILLOWBROOKE COURT AT COUNTRY HOUSE 85003 4830 KENNETT PIKE WILMINGTON DE 19807 2018-07-18 758 D 0 1 9EWR11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure medication regimens were free from unnecessary [MEDICAL CONDITION] medications for one (R29) out of 23 sampled residents. The facility failed to accurately monitor behaviors for [MEDICAL CONDITION] medications for R29. Findings include: Review of R29's record revealed: On 5/14/18, R29 was admitted to the facility with [DIAGNOSES REDACTED]. Review of R29's physician orders [REDACTED]. Review of R29's CNA tasks stated that R29's behavior symptoms were to be monitored every shift since admission in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 5/14/18, night shift on 5/14/18, day shift on 5/15/18, evening shift on 5/15/18, evening shift on 5/16/18, night shift on 5/16/18, night shift on 5/21/18, evening shift on 5/25/18, night shift on 5/27/18, evening shift on 5/28/18, and evening shift on 5/30/18. In addition, the only shifts where behaviors were documented was on 5/17/18 day and evening shift, which stated that R29 was repeating movements. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 5/16/18, the consultant pharmacist recommendation stated that R29 received an antipsychotic ([MEDICATION NAME]), but did not have a supporting indication for use documented. If current therapy was to continue, R29's chart needed to be updated to include: the specific diagnosis/indication that required treatment, and a list of the symptoms or target behaviors. On 5/30/18, the facility developed a care plan that stated R29 used [MEDICAL CONDITION] medications related to behavior management. Interventions included to monitor and record the occurrence of target behavior symptoms: combative or aggressive behavior with staff and others and false beliefs/hallucinations. Review of R29's CNA tasks revealed that R29's behavior symptoms were to be monitored every shift in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 6/3/28, night shift on 6/3/18, evening shift on 6/6/18, night shift on 6/6/18, evening shift on 6/9/18, night shift on 6/11/18, night shift on 6/13/18, night shift on 6/14/18, night shift on 6/16/18, evening shift on 6/20/18, night shift on 6/20/18, night shift on 6/22/18, day shift on 6/23/18, day shift on 6/24/18, evening shift on 6/27/18, night shift on 6/27/18, and night shift on 6/28/18. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 6/8/18, the physician wrote an order for [REDACTED]. Review of R29's CNA tasks revealed that R29's behavior symptoms were to be monitored every shift in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 7/1/18, evening shift on 7/5/18, day shift on 7/6/18, night shift on 7/6/18, night shift on 7/10/18, evening shift on 7/11/18, day shift on 7/14/18, and day shift on 7/15/18. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 7/10/18 the consultant pharmacist commented that R29 received [MEDICATION NAME] for depression without a concomitant antidepressant. The consultant pharmacist recommended to evaluate the continued use of R29's [MEDICATION NAME] for depression, and to provide detailed documentation of the specific diagnosis/indication requiring treatment, the symptom criteria/target behaviors, and perform ongoing monitoring of specific target behaviors. The facility failed to document the [DIAGNOSES REDACTED]. Findings were reviewed with E1 (NHA) and E2 (DON) on 7/18/18 at 2:00 PM. 2020-09-01