cms_NE: 12404
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12404 | ASHLAND CARE CENTER | 285140 | 1700 FURNAS STREET | ASHLAND | NE | 68003 | 2011-03-29 | 323 | E | 1 | 1 | 5DBO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E3 Based on observation and interview; the facility staff failed to implement fall prevention measures for 1 resident (Resident 37); failed to maintain water temperatures in 1 of 2 bathhouses at a level to prevent the potential for scalds which had the potential to effect 40 residents; failed to maintain 3 resident room at a level to prevent the potential for scalds with the potential to affect 8 residents. The resident sample size was 32. The facility census was 68. Findings are: A. Review of Review of Resident 37's quarterly MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 3/11/11 revealed that the resident's BIMS (Brief Interview Memory Screen) had a total score of a 6 (a score of 0-7 = severe cognitive impairment). The resident did not have any delirium, behavioral, or mood issues. The resident required extensive activities of daily living assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was on a toilet program trial. The resident's active [DIAGNOSES REDACTED]. The resident had a fall since last MDS without injury. The resident was on a nursing passive and active range of motion program. The resident used a wheelchair and walker for mobility assistance. Review of Resident 37's Fall Risk assessment dated [DATE] and 3/18/11 revealed a total score of 27. A total score of 25 or greater represents that the resident was at high risk for falls. Review of Resident 37's Transfer Tool dated 12/2410 revealed that the resident required limited assist to transfer. Review of Resident 37's of Nurse's Notes revealed that the resident fell on [DATE] with no injury. The resident was found on the floor and stated that the resident was trying to look outside. Review of Resident 37's Fall Investigation Worksheet dated 2/28/11 revealed that the resident stood up out of the resident's wheelchair and fell backwards hitting the resident's head. The resident had a lump of the back of the resident's head. The report did not state if the resident's alarms were on the wheelchair and if the alarms were sounding. Review of Resident 37's Care Plan dated 12/29/10 revealed that the resident was at high risk for fall according to Fall Risk Review Tool related to Dementia and poor safety awareness. The resident's Fall Risk Score was 27 indicating high risk on 12/17/10 and 3/18/11. The resident had a fall on 2/28/11 at 10 am self propelling the resident's wheelchair in room. The resident stood up and fell backwards. The resident sustained [REDACTED]. The resident fell [DATE] at 10:50 am was self propelling in hallway stood up and fell . The resident's goal was to have fewer occurrences of falls if possible weekly. Interventions included: Physical Therapy/Occupational Therapy/restorative referrals prn; call light usable and in reach; bed in lowest position; keep room clutter free; staff to anticipate needs (hunger, thirst, pain; bed and chair alarms; falling star program; fall documentation analysis to determine cause; dycem in wheelchair and recliner prn (as needed); keep items in reach; gait belt with ambulation; frequent checks; intervention added 2/28/11 staff to keep resident in sight when propelling in wheelchair staff educated and the resident must be in the resident's easy chair when in room. Random observations of Resident 37 revealed: -3/23/11 at 2 pm the resident was lying in bed the resident's bed was in the low position. Bed alarm on. -3/24/11 at 9:30 am the resident was seated in her easy chair with her feet elevated on her footstool. The resident's chair alarm was on. The resident's call light was within reach. -3/28/11 at 6:45AM resident up in wheelchair in room alone with wheelchair alarm on. TABS unit on bed. At 6:55 AM the DON (Director of Nursing) assisted the resident to the dining room table. -3/28/11 at 8: 45 AM Resident up in wheelchair with wheelchair pressure alarm on. Resident was assisted to the toilet by NA (Nurse's Aide) A and NA B and back to the resident's wheelchair. The resident was left in the resident's room in the wheelchair unattended. -3/28/11 at 11 am the resident was seated in wheelchair with an over the bed table in front of the resident. The resident was in the room unattended. Interview with the DON on 3/29/11 at 11:19 am revealed that the DON was unable to determine if the resident had alarms on the resident's wheelchair when (gender) fell on [DATE]. The DON stated that the DON was aware that the nurse did not document the resident's fall in the resident's medical record. The DON acknowledged that the resident fell from the wheelchair and the fall report stated that the resident's bed was in the low position. The don acknowledged that yesterday (3/28/11) the resident was seated in the wheelchair in the resident's room and should have been in the resident's easy chair with the alarm. She stated that the resident falls was usually from reaching for a magazine or a drink. Interview with the resident's family member on 3/24/11 at 1:25 pm revealed that the resident was pretty good about turning on the call light to transfer or go to the bathroom. B. Observation of resident rooms 117 and 119 located on the Special Care Unit shared bathroom water temperature revealed: -On 3/23/11 8:47 am the bathroom water temperature was 123.9 degrees Fahrenheit. -On 3/23/11 at 9:14 am the bathroom water temperature was 131degrees Fahrenheit. The temperature was witnessed by MA (Medication Aide) C. -On 3/24/11 at 8 am the bathroom water temperature was 123 degrees Fahrenheit. -3/28/11 at 7:09 the bathroom water temperature was 125 degrees Fahrenheit. Interview on 3/24/11 at 8:15 am with the Maintenance Director revealed that the water temperature on 3/23/11 in the evening for rooms 117 and 119 was 125 degrees Fahrenheit. The Maintenance Director stated that a mixer valve was ordered for the bathroom was ordered and it would take a few days to get in. It will take a few days to get a mixer valve in. The Maintenance Director thought the elevated temperature could be because the room was next to the bathhouse. Interview with Resident 69 on 3/24/11 at 8 am who resided in 117 stated that one day the water in the bathroom was lukewarm the next day the water was hot. Environmental tour conducted on 3/29/11 at 8:40 am - 10:05 am Maintenance Director revealed: -Room 208 the bathroom water temperature was 123.9 degrees Fahrenheit. -Room 201 the bathroom water temperature was 124 degrees Fahrenheit. -Country Bathhouse whirlpool tub was 120.6 degrees Fahrenheit. The Maintenance Director stated that there was not an anti-scald prevention device on the whirlpool tub. Interview with Bath Aide D stated that the water temperature is taken before every bath and logged. The BA stated that most residents prefer the bath water to be between 97 - 99 degrees Fahrenheit. Rooms 117 and 119 the bathroom water temperature was 127.9 degrees Fahrenheit. The Maintenance Director stated that the mixer valve had not arrived yet to lower the water temperature. Interview with the DON revealed that none of the facility residents had sustained a burn from the tap or bath water. The DON stated that 40 residents are bathed in the Country Bathhouse. The resident's individualized water temperature logs were reviewed with the DON and none of the temperatures exceeded the 103 degrees Fahrenheit. According to Antiscald.com a water temperature at 131 degrees Fahrenheit would cause a second degree burn in 17 seconds and a third degree burn in 30 seconds. A water temperature of 120 degrees Fahrenheit would cause a second degree burn in 8 minutes and a third degree burn in 10 minutes. | 2014-07-01 |