cms_NE: 5511
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5511 | GOOD SAMARITAN SOCIETY - HASTINGS VILLAGE | 285072 | 926 EAST E STREET | HASTINGS | NE | 68901 | 2016-12-22 | 309 | D | 1 | 0 | B6C911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to assess and treat a laceration in a manner to promote healing for one resident out of the 4 sampled residents. The facility census was 105. Findings are: Review of the undated [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-30-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 15 which indicated Resident 100 had no cognitive impairment. Resident 100 required limited assistance of one staff with bed mobility, transfers, dressing, and toileting. Review of the Incident Report dated 11-30-16 revealed Resident 100 was found on the floor at 1:40 PM with an injury of an 8 x 5 cm (centimeter) skin tear on the left lower leg on the front side. The nurse cleansed the wound and applied skin prep (a liquid film-forming dressing applied to the skin which prepared the skin for adhesives) to the skin that surrounded the wound. Next the nurse applied steri-strips (thin adhesive strips used to close open wounds) to the wound and wrapped the leg in a dry dressing. The Physician was notified of the resident's fall and of the skin tear to the leg. Review of the Physician orders [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) TAR (Treatment Administration Record) revealed no nursing orders to monitor or treat the skin tear on the left lower leg. Review of the Nursing Notes revealed no assessment of the skin tear wound to the left lower leg. Interview on 12-22-16 at 3:42 PM with the Facility Nursing (UM) Unit Manager on the unit Resident 100 resided on revealed the UM had not observed the skin tear to the resident's leg. The UM spoke to the nurse who initially assessed the wound and was informed the wound was a large skin tear. The UM revealed the UM had been informed that, for the top portion of the skin tear, the nurse was able to roll the skin back over the wound and steri-strip the area. For the lower portion of the skin tear wound, the skin was missing and therefore the nurse was not able to steri-strip that portion of the wound together. Interview on 12-22-16 at 2:35 PM with Nurse-A revealed Resident 100 was seen on 12-14-16 by the resident's PCP (Primary Care Physician) at the Physician's clinic. The nurse revealed the physician had assessed the wound to the left lower leg as a large gapping full thick untreated laceration. The Physician informed the resident and resident's spouse that the wound should have had sutures initially after injury and that it was not a skin tear. Review of the PCP clinic notes dated 12-14-16 revealed the Physician was notified on 11-30-16 by the facility that Resident 100 had received a skin tear to the left lower leg. As the area was not suturable, the facility would dress the wound. On 12-14-16, the wound was assessed as a large full thickness laceration which remained opened and was draining serum constantly. Interview on 12-22-16 at 4:11 PM with the Resident 100's spouse revealed the spouse had observed the wound on the left lower leg after the incident had occurred and had felt the wound was large and required sutures. The spouse denied the resident having had reinjured or bumped the left lower leg since the resident had left the faciity on [DATE] up through the time the resident saw the physician on 12-14-16. | 2019-11-01 |