cms_NE: 25
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 25 | DOUGLAS COUNTY HEALTH CENTER | 285019 | 4102 WOOLWORTH AVENUE | OMAHA | NE | 68105 | 2019-08-12 | 689 | G | 1 | 0 | 7ED911 | **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 staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls. | 2020-09-01 |