cms_NE: 4492
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4492 | MIDWEST COVENANT HOME | 285062 | P O BOX 367, 615 EAST 9TH STREET | STROMSBURG | NE | 68666 | 2016-06-30 | 155 | D | 0 | 1 | ER4L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 (4) Based on record review, observation, and interview; the facility failed to ensure residents were allowed choices related to the use of personal safety alarms. This violation had the potential to effect one resident (Resident 45). The facility census was 39. Findings are: A review of the medical record for Resident 45 revealed INTERDISCIPLINARY PROGRESS NOTES (IPN) including: -a note dated 1/24/16 at 8:52 PM indicated Resident 45's family member did not want the resident to be wearing a TABS (a personal safety alarm which attaches to the persons clothing to alert staff to a possible unassisted transfer) alarm during the day time, the family member had detached the alarm from the resident while in the facility and did not reattach it prior to leaving. Resident 45 was upset when the alarm was replaced by staff, documentation indicated was ok with it after explanation and understands why the alarm was needed. -a note dated 1/24/16 at 10:17 PM revealed Resident 45's alarm was noted to be disconnected from the resident upon an LPN's (Licensed Practical Nurse) entrance into the resident's room to answer the call light. Resident 45 stated my daughter doesn't want me to have those alarms on, I'm supposed to be walking so I can go home The resident was assisted to the bathroom with walker, gait was unsteady. Resident 45 was reminded to put call light on when finished, and was compliant with the reminder. The documentation indicated Resident 45 was assisted back to the chair, and the TABS was placed on resident without incident or complaint from the resident. -notes dated 1/26/16 at 11:27 and 11:28 PM revealed that scheduled/ordered treatments for Resident 45 were held due to the Resident's mood. The documentation indicated Resident 45 was angry, agitated, and believes staff was lying to (gender) about having to wear alarms. -a note dated 1/28/16 at 1:54 PM indicated Resident 45's functional ability was: to be independent in the resident's room to the bathroom using a walker or wheelchair; required assistance from one staff member in halls. A review of Resident 45's MDS (Minimum Data Set-a mandatory assessment tool used for care planning) information revealed an Admission assessment dated [DATE]. The assessment indicated Resident 45's BIMS (Brief Interview for Mental Status) score was 14 (13-15 indicates the person is cognitively intact). A review of the facility's Care Plan dated (MONTH) (YEAR) for Resident 45 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident 45: exhibited shortness of breath and anxiety, was sometimes confused, was alert, and was usually able to make needs known. The resident had been hospitalized prior to coming to the Skilled Nursing Facility for strengthening, and planned to discharge to an Assisted Living Facility when able. An intervention with start date of 1/30/16 revealed Resident 45 required assist from one staff member, using a gait belt and walker, to ambulate in the halls. The documentation indicated the resident needed assist with both transfers and walking upon admission, but now could transfer and walk in the resident's room with a wheeled walker or wheelchair. The safety equipment used to assist Resident 45 included documentation of a TABS monitor in the evening and night due to confusion at those times, but with my independence it has been DC'D (discontinued). An observation on 6/27/16 at 11:46 AM revealed Resident 45 seated in a recliner in the resident's room. A TABS type alarm was noted to be attached to the resident. An interview on 06/30/2016 at 11:32 AM interview with Resident 45 revealed the facility's use of an alarm for the resident caused an increase in anxiety which in turn caused Resident 45 to have increased difficulty with breathing. The resident reported I told them I didn't want it. An interview on 06/30/2016 at 11:58 AM with the MDS Coordinator revealed Resident 45 continued to be own person, making (gender) own decisions. Resident 45 did not have a DPOA (Durable Power of Attorney) for Healthcare. A further review of Resident 45's IPNs dated 01/18-06/30/2016 revealed no documentation indicating the facility had discussed possible safety interventions with the resident. | 2020-04-01 |