cms_NE: 12704

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.

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
12704 GOOD SAMARITAN SOCIETY - ATKINSON 285177 409 NEELY STREET ATKINSON NE 68713 2010-07-21 323 E     O8E211 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations, record review and staff interview; the facility failed to assure the environment was free from safety hazards as Resident 34's side rail (A side rail is a barrier extending upward at the side edges of the bed. It can be located on either one or both sides of the bed and extends either a partial distance or the entire length of the bed. The side rails can be used by the resident to assist with transfers, turning, and bed mobility.) use was not assessed as a potential risk for injury. In addition, the medication room door was left open and the area was not monitored for 10 minutes on 7/19/10 which allowed access to 10 residents of the facility who were at risk for wandering. A box of medications was sitting on a shelf in the medication room. Total sample size was 12 and facility census was 47. Findings are: A. Review of Resident 34 ' s Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/9/09 indicated [DIAGNOSES REDACTED]. The same MDS indicated the resident had short-term memory problems and moderately impaired cognitive skills for daily decision-making, required total assistance with transfers and bed mobility, and used a type of side rail daily. Review of the Bed Rail/Side Rail/Assist Bar Screening Tool dated 10/3/09 revealed side rails and/or other devices were not indicated for Resident 34. Review of a Resident/Visitor Incident Report dated 10/25/09 revealed Resident 34 had been restless while in bed and got left hand caught " between Assist bar & (and) mattress " . The form indicated Resident 34 sustained a 3 centimeter (cm) by 5 cm bruise to the left wrist with a 1 cm skin tear at the center of the bruise. The form indicated the facility initiated use of a U-shaped pillow (a pillow in the shape of a U with long sides that can be draped around the resident and used to position the resident in bed) since the resident was " restless & turning self & getting hand & feet off bed & caught in mattress " . Review of MDS ' s dated 1/5/10 and 4/5/10 indicated Resident 34 required total assistance with transfers and bed mobility, and used a type of side rail daily. Review of the Comprehensive Care Plan (CCP) dated 4/7/10 revealed the use of side rails on Resident 34 ' s bed was not addressed. Review of the MDS dated [DATE] indicated Resident 34 required total assistance with transfers and bed mobility and no side rail was being used. During observation of nursing care on 7/15/10 from 8:00 AM to 8:15 AM, Nursing Assistant (NA) - D and NA - H dressed Resident 34 and provided morning care. When turning Resident 34 from side to side while dressing and/or applying lift sling, a ? length side rail was raised and the resident was cued to hold on to the side rail to support self on side. Resident 34 was transferred from bed to wheelchair and wheeled to the dining room. On 7/15/10 at 10:40 AM, Resident 34 was observed resting in bed with ? length side rails in the up position on both sides of the bed. On 7/19/10 at 11:20 AM, Resident 34 was observed resting in bed. The ? length side rail on 1 side of the bed was in the up position. At 1:50 PM on the same day, ? length side rails were in the up position on both sides of the bed. During interview on 7/20/10 from 1:00 PM to 2:10 PM, the Director of Nursing (DON) verified Resident 34 ' s side rails were to be used during provision of cares for assistance with positioning; however, they were not to be left in the up position while the resident was resting in bed. B. Review of a list of residents dated 713/10 revealed the facility identified 10 residents at risk for wandering. The door of the medication room (located behind the nurses' station) was observed open and there were no staff members present in the area on 7/19/10 from 9:10 AM until 9:20 AM. There was a box of medications on the shelf in the medication room which were accessible to anyone who entered the medication room. After being alerted to the situation at 9:20 AM on 7/13/10, the Director of Nursing (DON) locked and closed the medication room door. The DON stated the medication room door was to be locked at all times when staff members were not in the area. 2014-04-01