cms_NE: 35
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 35 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2017-05-04 | 312 | D | 1 | 0 | 04EU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1 Based on observations, record review, and interviews; the facility failed to provide assistance with a shower and left the dependent resident unattended for 2 and 3/4 hours for 1 resident (Resident 603) out of 3 sampled residents. Resident was unable to use the call light to call for needed assistance. The facility census was 138. Findings are: Review of the face undated sheet for Resident 603 revealed an admission date of [DATE]. Review of the undated face sheet revealed [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-11-17 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 603 was cognitively intact. Resident 603 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and bathing. Interview on 04-26-17 at 10:00 AM in the resident's room revealed a few weeks ago Staff A put the resident into the shower and performed a 10 minute rinse to the left leg. When completed, Staff A left and said Staff A would be back in 5 minutes and the resident was left sitting in the shower without a call light for over 2 and 1/2 hours. At first the resident thought time was just going by slowly, then the resident realized the resident had been forgotten. At one time the resident thought the resident heard someone come into the resident's room so (gender) yelled out is anyone out there. Resident 603 revealed however the resident's voice was very soft and no one came into the bathroom. Resident 603 revealed the bathroom had a call light but it was across the room by the toilet and the cord was not long enough to have reached the resident. The resident revealed at that time, the resident was not to transfer alone and the wheelchair was not close so the resident could have reached it even if the resident would have wanted to have tried to transfer. Resident 603 revealed Staff B from the evening shift entered the bathroom while passing fresh water pitchers and emptied the old water in the sink and found the resident on the shower chair. Staff B asked the resident what the resident was doing in the shower then went and informed the charge nurse and they returned and transferred the resident into the wheelchair. Resident 603 denied any physical injury from the incident. Observation on 04-26-17 at 10:20 AM revealed the resident shower was in the bathroom of the resident's room. The shower chair was a permanently fixed chair to the wall and not a chair with wheels. The only call light in the bathroom was across the room by the toilet. Review of the facility investigation report revealed on 04-08-17 at approximately 2:00 PM a shower was given to Resident 603. The resident was dressed followed by the wound treatment to the left leg by the Staff [NAME] The resident was left sitting on the shower chair to allow the [MEDICATION NAME] to dry before the resident was transferred back into the wheelchair. The call cord was not long enough to reach the resident in the shower. Staff A left the resident to go give report to the oncoming shift. Staff A revealed (gender) believed report was told to the oncoming shift of Resident 603 being left in the shower. The oncoming nurse, Staff C, denied being told Resident 603 was in the shower. The resident was taken out of the shower at 4:45 PM when Staff B found the resident when Staff B emptied a water pitcher. Review of the Progress Notes revealed no documentation of the incident. On 04-08-17 at 9:35 PM it was documented a general overall skilled assessment of the resident which revealed resident had no visible sores noted. Interview on 04-26-17 at 4:45 PM with the DON (Director of Nursing) confirmed the incident had occurred and the staff involved were disciplined. The resident was left unattended on the shower chair in the resident's bathroom without a call light for 2 hours and 45 minutes. | 2020-09-01 |