cms_NE: 12972

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
12972 THE LUTHERAN HOME 285171 530 SOUTH 26TH STREET OMAHA NE 68105 2010-09-23 225 E     ZEZV11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 12-006.02(8) Based on record review and interview; the facility staff failed to investigate and report allegations of staff to resident mistreatment for [REDACTED]. The sample size was 12 plus 9 non sampled. The facility census at the time of survey was 45. Findings are: A. Record review of the Facility Abuse Policies and Procedures dated 12/09 revealed that employees are required to report and occurrences of potential mistreatment or alleged abuse they observe, hear about, or suspect to the Administrator, Director of Nursing, or Social Services Director immediately. It will be the responsibility of the Administrator to report every instance of alleged resident abuse to the Nebraska Department of Health and Human Services immediately. Record review of Resident 8's Admission Face Sheet dated 7/28/10 revealed [DIAGNOSES REDACTED]. Record review of a Physicians Progress Note dated 9/7/09 revealed a note from Resident 8's Physician that read: "Pt also complained (gender) had broken ribs from being thrown in the bed." The progress note and the accompanying physician order [REDACTED]. Record review of the facility investigation files since 9/1/09 revealed that there was no evidence the allegation of mistreatment for [REDACTED]. Interview on 9/22/10 at 12:10 PM with the Director of Nursing (DON) confirmed that the Facility Administrative Staff were not aware of this allegation and did not investigate or send in a completed investigation to the required State Investigation Agencies. The DON stated that the facility staff should have contacted the DON with this allegation so that an investigation could be done and a report sent to the required state agencies. B. B. Resident 15 had been admitted [DATE] and discharged [DATE]. According to the [DIAGNOSES REDACTED]. Review of Resident 15 ' s nurse notes revealed an entry dated 2/23/10 at 2300 -"While CNA (certified nurse aide) was providing cares to patient, accidentally pulled tube feeding out with balloon intact. Balloon deflated & re-inserted. Placement verified per 30 cc of air [MEDICATION NAME] regimentals of 15 ML. Restarted feeding about 001. Interview on 9/23/10 at 1:15 PM with the Director of Nursing (DON) revealed there was no incident report available related to any staff member pulling out a [DEVICE]. The DON noted that nurses do not put in [DEVICE]s. Also that Resident 15 always went to Nebraska Medical Center emergency room for treatment of [REDACTED]. The DON noted that the resident has a long history of the [DEVICE] coming out and being sent to ER to have it replaced. During the status meeting on 9/23/10, at 2:05 PM, the incident in the nurse notes dated 2/23/10 was brought to the Don ' s attention. She replied, " I didn ' t know anything about that incident. We do not do (Resident) [DEVICE]s. It is not expected or the policy for nurse ' s to replace [DEVICE]. " After DON reviewed the nurse ' s notes replied, " Yes, it appears the nurse did put it back in. " On 9/27/10 at 10:30 AM, information by fax received from the DON related to interviews of staff working during the time of the incident 2/23 to 2/24/2009. Registered Nurse-(RN)-H worked the floor at the time of the incident. RN-H confirmed the doctor was not notified, the resident was not sent to the ER for [DEVICE] replacement, and incident was not made out, and RN-H did replace the [DEVICE]. RN-H did confirm the tube was connected back up and the tube feeding running. On 9/27/10 at 10:30 AM, information by fax received from the DON of interviews of staff working during the time of the incident 2/23 and 2/24/2009 revealed License Practical Nurse (LPN)-I did report that the CNA ' s had reported the [DEVICE] had been pulled out. LPN-I did note that she felt Resident 13 ' s tube had accidently fallen out during positioning by the CAN ' s. LPN-I did confirm the [DEVICE] had been replaced by RN-H. C. On 9/22/10 review of 13 investigations completed by facility staff revealed 4 failed to have been completed and faxed timely to the state office within the required 5 day time frame: 1. Resident 15 with report incident 03/08/10; report faxed to state office 03/16/10 -total 7 days. 2. Resident 21 -incident occurred 03/10/10; report faxed to state office 03/08/10 -total 6 days. 3. Resident 19 -incident occurred 05/25/10; report faxed to state office 06/03/10 -total 7 days. 4. Resident 20 -incident occurred 06/23/10; report faxed to state office 07/12/10 -total 13 days. Review of the facility's ABUSE and NEGLECT Policies and Procedures dated 12-20-09 -revealed under PART V - Reporting/ Protecting/ Investigation - item 12. C. 5) (f) Final report within 5 working days of initial report fax completed Abuse/Neglect Notification Report with care plan, nurse's notes, MAR/TAR, any other supporting documentation showing the facility thoroughly investigated the event and action taken assuring the resident is safe from further occurrences. On 9/23/10 at 3:00 PM interview with Nurse-A , Director of Nurses and Staff -B, and the social worker confirmed the 4 investigations failed to be completed and faxed with in the policy to have them completed in 5 days. 2014-01-01