cms_NE: 5781
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5781 | HILLCREST HEALTH & REHAB | 285133 | 1702 HILLCREST DRIVE | BELLEVUE | NE | 68005 | 2015-06-03 | 323 | D | 0 | 1 | EJB611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement interventions to prevent falls for 2 residents (Resident 552 and 568). The facility staff identified a census of 83. Findings are: A. Record review of a Resident Incident Reporting Form dated 5-19-2015 revealed Resident 552 was found on the floor. Record review of Resident 552's Comprehensive Care Plan (CCP) dated 4-30-2015 revealed Resident 552 was was identified at risk for falls. The goal identified for the residents was to have no falls with injury. Interventions identified on the CCP included the following: -Hi/Low bed, keep in (the) lowest position with floor mats on both sides. -Fall Alarm with staff to check placement and function every shift. -Patient will not be in room alone. Observation on 6-01-2015 at 1:06 PM revealed Resident 552's bed was in a waist high position and had 1 mat under the bed. Observation on 6-01-2015 at 2:09 PM revealed Resident bed remained at waist high and had 1 mat under the bed. Observation on 6-01-2015 at 2:22 PM with Registered Nurse (RN) A revealed Resident 552's bed was at waist high level and had 1 fall mat under the bed. RN A confirmed Resident 552's bed was not in the low position and that there was 1 fall mat under the bed. Observation on 6-02-2015 at 11:15 AM revealed Resident 552's bed was not in a low position and had 1 fall mat under the bed. Resident 552 was seated outside of the room and the personal alarm was not attached. An interview was conducted with Licensed Practical Nurse (LPN) B on 6-02-2015 at 11:17 AM. LPN B confirmed Resident 552's alarm was not attached to the resident. B. Resident 568 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident Incident Reporting Form dated 5/22/15 at 8 PM revealed Resident 568 was found on the floor. Resident 568 reported standing at bedside attempting to use the urinal when Resident 568 fell . A review of Causal Factors report for Resident 568 completed on 5/23/15 revealed the following interventions were implemented to prevent falls: instructed resident to call for assistance and a bed alarm was placed. Nurse Tech Care Plan for Resident 568 printed on 6/2/15 identified Resident 568 as being at high risk for falls and alarms are to be used with Resident 568. Observations at 6/1/15 at 2:57 PM revealed Resident 568 seated in recliner in resident room. Resident 568's fall alarm was on Resident 568 wheelchair located in another area of the room. Observations on 6/2/15 at 1:20 PM revealed Resident 568 resting in the bed. Fall alarm was laying in a chair by the bed and not attached to Resident 568. In an interview on 6/2/15 at 1:29 PM, Registered Nurse C checked report and identified that Resident 568 was to have the fall alarm in place. In an interview on 6/2/15 at 2:11 PM, Registered Nurse Clinical Manager D confirmed alarms were indicated on Resident 568's nurse tech care plan and should be in place. | 2019-09-01 |