cms_MT: 1504
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1504 | BLACKFEET CARE CENTER | 275133 | 728 S GOVERNMENT SQ | BROWNING | MT | 59417 | 2019-10-31 | 600 | G | 1 | 0 | DC1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident received timely treatment for [REDACTED].#74) of 22 sampled residents. Findings include: During an interview on 10/30/19 at 2:30 p.m., staff member D stated she received a report of bruising to resident #74 on 9/22/19. Staff member D stated bruises were to be reported to the DON or Social Services upon observing them. Staff member D stated nursing did not report the bruising like they should have. During an interview on 10/30/19 at 3:00 p.m., staff member B stated if a CNA finds a bruise, they are to fill out a pink slip and give it to the nurse. Staff member B stated the nurses are to report to the DON, who then would follow up. Staff member B stated the bruise would be assessed and documented in the medical record. Staff member B stated she had received a report about a bruise on resident #74's shoulder on 9/19/19. Staff member B stated it was first reported as a small bruise on the resident's arm and worsened from there. Review of resident #74's nursing progress notes, from 9/19/19 through 9/22/19, showed the following: -9/19/19 at 6:45 p.m., CNA stated that she had found a small bruise to her Right shoulder. bruise small and approx quarter in size on the upper arm. (sic) -9/20/19 at 3:28 a.m., Resident has a bruise on right shoulder. -9/21/19 at 5:03 a.m., 0800 during showing resident a large bruise on right frontal axilla, reported by the CN[NAME] (sic) -9/21/19 at 6:17 p.m., (Resident name) has a huge bruise from the top of inner right arm to approximately the anticubital area. Unknown cause. Pink slip filled out and turned into the DON. (sic) -9/22/19 at 2:31 a.m., Bruising of RUE, beginning at the top of bicep to above inner elbow. Noted 15cm x 6cm. At top of bicep is a hard raised swelling-measures 7cm x 5cm. measured in an X formation as swelling is not round but oblong in shape. Assessment and configuration of bruising and area of swelling-It appears someone may have gripped res with a hand high up on UE, to pull res by RUE while repositioning or during a transfer from one horizontal surface to another. Swelling location and slight bruising impression similar to thumb placement on inner deltoid give a likeness to such a grip when nurse personally compared hand to bruise to substantiate possibility of this theory. Approx 2215 (10:15 p.m.) res scowling and while UTA and decipher vocalization-the tones were distress in nature. Administered children's IBU as ordered. Effective and assessed 0 pain level. Resting quietly and no distress noted during measuring of trauma of RUE. (sic) -9/22/19 at 6:44 p.m., Noted large bruising on (resident name) inner arm this AM. As CNA putting night gown on (resident name) we discovered more bruising on her neck and back with shoulder looking a little misplaced. Nurse spoke with (physician name) and asked if he could do an x-ray of her shoulder. Nurse has tried to contact her family that live locally unsuccessly (sic) so (family name) her brother who lives out of town was called. His number is (phone number) and he will try to locate local family to inform them of (resident's name) being sent to ER. Nurse left message with DON. (sic) -9/22/19 at 8:51 p.m., Social Services was contacted by (nurse's name) at approximately 7:28 p.m. She explained to the Social Worker that (resident name) had to be sent up to the ER due to bruising that was found on her upper/inner arm, neck, and back. They also notice that she was favoring her right shoulder, so they call the ER Dr. and he told them to send her up so that she can be xrayed. Social Services immediately responded by telling (nurse's name) that she was on her way in. Social Services arrived and it was explained further to her that it was determined by the xrays that her right shoulder is in fact dislocated. ER explained that they would be contacting Law Enforcement. Shortly there after, Officer (officer's name) showed up and began asking questions. He asked Social Services about finding out who works both shifts for the past 2 weeks that he would need a schedule of some sort. About that time CNA (CNA's name) showed up and began answering questions asked by the officer and then he asked Social Services to get everything and he would come back and get everything. Social Services has talked with both reporting CNA's they were helpful in giving names, dates and scheduling that are needed to help complete the investigation. This incident will be reported to Bounds (electronic abuse reporting program), Law Enforcement. Local Ombudsman and Elder Protection and a full investigation will be completed within the five days from today. (sic) Review of a Communication Board form showed the resident had bruising to her buttock and right shoulder on Thursday (9/19/19). All bruises were reported by CNAs on pink skin alert sheets and turned into charge nurses. On 9/21/19 the bruise had grown in size. On 9/22/19 the bruise had grown more and went around her shoulder and her back. On all occasions the CNAs reported the bruising to the nurses. Review of resident #74's progress notes showed the resident received [MEDICATION NAME] on 9/21/19 at 9:24 p.m. and on 9/22/19 at 2:00 a.m. Review of the record failed to show ongoing assessment and monitoring of the resident's pain as a result of the bruising. Review of resident #74's clinical record showed there was a three-day lapse between the discovery of the bruising, and the resident being sent out for treatment. Review of resident #74's medical records, dated 9/22/19 from the hospital, showed the resident had bruising over her right shoulder, right upper arm and eyeballs bilaterally. The right shoulder x-ray imaging revealed mildly displaced [MEDICAL CONDITION] neck of the right humerus. The triage assessment showed the resident arrived from the care center with bruises in multiple stages of healing. Under Orders for Today, the record showed the resident was admitted for further evaluation and protection. | 2020-09-01 |