cms_NE: 12944

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.

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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
12944 SUMNER PLACE 285002 1750 SOUTH 20TH STREET LINCOLN NE 68502 2010-09-07 323 G     SCJJ11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to safely secure 2 residents (Residents 1 and 2) during transport in the facility van from a resident sample size of 5. The facility census was 100. Findings are: A. Review of Resident 1's ER (Emergency) Injury Summary dated 8/10/10 revealed that the resident had sustained a fall with a C2 (2nd cervical vertebrae) type 3 fracture; and abrasions to the posterior scalp and left hand. Review of Resident 1's Spine Trauma Consult dated 8/10/10 revealed that the resident was in a van today and when the van moved forward, the resident's wheelchair fell backwards, and the resident struck (gender) head. The resident denied loss of consciousness. The resident complained of neck pain. The resident was able to shrug the resident's shoulders and elevate the resident's legs off the bed. The resident denied paresthesia (tingling sensation) in the resident's arms or legs. The C spine (Cervical spine) x-ray revealed an acute C2 type-3 fracture through the body with minimal displacement. The physician ordered a Miami J neck collar for the resident to wear. Review of Resident 1 Nurse's Notes on 8/10/10 at 4 PM revealed that the resident's wheelchair tipped over in the van and the resident was taken to the doctor's office. The resident was transported from the doctor's office to the hospital ER. Review of Resident 1's Annual MDS (Minimum Data Set: a federally mandated comprehensive care plan used for care planning) dated 6/20/10 revealed that the resident required limited assistance for transfers and ambulation. The resident was able to eat independently with set up assistance. The resident did not have range of motion limitations. Review of Resident 1's Significant Change MDS dated [DATE] revealed that the resident required extensive to total assistance with all activities of daily living including eating. The resident was non ambulatory. The resident had other range of motion limitations. Review of Resident 1's Physician Facsimile revealed: -On 8/12/10 at 2:40 pm the facility staff notified the physician that the resident was having pain and requested a routine pain medication. The physician ordered Percocet 5/325 mg (milligrams) 1 orally every 6 hours. -On 8/17/10 Nutrition Review stated that chewing was painful for the resident and resident's food intake had declined. An order was received to change the resident's diet from a ground meat diet to a pureed diet. The resident was fed all meals. -On 8/25/10 the resident complained constantly of pain even though on Percocet 5/325 1 po (orally) (orally) (orally) qid (4 times daily) (4 times daily) (4 times daily) and Tylenol for breakthrough pain. Resident 1's physician progress notes [REDACTED]. The resident was weakly able to move all extremities. The resident could raise both legs, but could not fully raise (gender) arms. The cervical x-ray 8/17/10 showed no displacement of the C2 fracture, but function is less. A MRI (Magnetic Resonance Imaging) was ordered. Review of Resident 1's physician progress notes [REDACTED]. The resident had tight stenosis with spinal cord compression. Review of Resident 1's Progress Note dated 8/27/10 revealed that the resident's C1-5 fusions due to Cervical 2 fracture with stenosis. Review of Resident 1's Pain Assessment revealed: -On 3/20/10 and 6/18/10 the resident did not display signs of pain. -On 8/12/10 the resident displayed non-verbal signs of pain as evidenced by: crying/ moaning; aggression; increased body movements; guarding of the neck; facial grimacing; increased restlessness; and irritability. The resident only had relief from pain treatments 10% of the time. -On 8/31/10 the resident demonstrated non-verbal signs of pain with increased rest periods. The resident's pain treatments provided 100% relief. Review of Resident 1's Community Transfer Sheet dated 8/31/10 revealed that the resident had Prafo braces for hand contractures. The resident had red non blanchable sport to the resident's occipital lobe of the head (back of the head). The resident had skin breakdown from the Miami J neck collar on the front and back of the resident's chest on admission and now was wearing a soft neck collar due to the resident's poor skin integrity. Review of Resident 1's Nurse's Notes dated 9/5/10 at 1 pm revealed that the resident had an elevated temperature of 100.6 degrees F and an increase in wound drainage noted to the lower portion of the resident's dressing. The skin surround the staples were red and green drainage was around the staples. The resident was transported to the hospital. Interview with RN (Registered Nurse) A on 9/2/10 at 12:30 PM revealed that the resident was hospitalized for [REDACTED]. Review of the Van Driver A's personnel file revealed that the van driver's last competency for van driving was completed on 9/13/06. The van driver's MVR (Motor Vehicle Record) was checked yearly per the facility policy, but Van Driver A did not have the yearly competency as required per their facility policy. Review of Van Driver A's interview with facility staff, dated 8/11/10, following the accident which occurred on 8/10/10 revealed that the van driver did not secure the resident's wheelchair with the front straps. When the van driver accelerated the van on 33rd and South Streets in Lincoln, the van driver heard a boom and "Let me up!" The van driver stopped the van and went to the back where the van driver found the resident tipped over in the wheelchair with blood on the floor. The van driver assisted the resident to an upright position. A police officer assisted and the resident was transported to the resident's physician's office and the resident was later transported to the hospital for evaluation. Interview with the facility Administrator on 9/2/10 at 3 PM revealed that Van Driver A was the van program instructor which started in 2006 and therefore Van Driver A did not have a competency since 2006 in the van driver's record. Interview with the Administrator on 9/2/10 at 3:15 PM revealed that Van Driver A was instructed on the blue van in which the accident occurred when it was new by the corporate staff a year ago, but there is no documentation of the orientation to the new van found by the administrator. B. Review of records identified that Resident 2 was involved in an accident while riding in the facility van on 08/24/2010 at 10:20AM. Records identify that Resident 2 was in a wheelchair that was positioned in the back of the van for transporting to a scheduled physician appointment. The van was at a complete stop at the intersection of South Street and 20th. When Employee B (the van driver) accelerated from the stop turning onto South Street. Resident 2 tipped over backward while sitting in the wheelchair. Resident 2 was quickly transported by ambulance to BryanLGH East for emergent care. emergency room services and assessments revealed that Resident 2 had bruises on the left arm and chest and an abrasion on the back of head. Extensive x-raying and a CT scan was done to rule out any further injuries. Morphine was administered for pain and ice bags were positioned over bruised areas. Resident 2 was released on the same day and returned to Milder Manor. Facility Administration and Director of Nursing as well as family member were immediately notified of the incident. Observation of Resident 2 during the Noon Meal on 09/07/2010 and interview with Employee C, assisting Resident 2, revealed: -Resident 2 had to be fed prior to the accident as well as the same. Resident 2 has a fair appetite and drinks fluids with assist. Employee C stated that everything is the same for Resident 2 as before the accident. Interview with the facility Administrator on 09/07/2010 at 1:30PM revealed: It has been acknowledged that the van driver, a long time employee of the facility was approved to drive the van and do so as a substitute for the regular full-time driver. This employee had driven this specific van before. During the investigation Employee B acknowledged that the forward straps had not been secured to the front wheelchair wheels to secure the chair for transport. The driver explained, "I forgot". The van was taken out of service and sent to the home office for inspection. Employee B had attended the required inservice on 08/19/2010 that reviewed the facility policy and procedure on proper restraint of wheelchairs in the van. Employee B is no longer allowed to drive the facility vans. Resident 2 is recovering from the accident injuries without observed complications. Resident 2 has returned to a regular routine and employees observe previous demeanor prior to the accident. 2014-01-01