cms_NE: 6021

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
6021 ROCK COUNTY HOSPITAL LONG TERM CARE 2.8e+279 100 EAST SOUTH STREET BASSETT NE 68714 2015-12-10 225 D 0 1 77700000000000.0 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report and/or investigate potential allegations of abuse for 2 residents (Residents 14 and 18). The facility census was 28. Findings are: A. Review of the facility Abuse Reporting and Investigation policy (revision date 8/2010) included the following: -In all cases of alleged abuse/neglect the facility was to intervene in the situation, report the situation to the proper authorities, investigate the allegation and prevent abuse/neglect while the investigation was in process. Documented evidence the facility intervened, reported, prevented abuse/neglect and completed an investigation was to be completed. -The abuse reporting procedure was to be initiated when an accident with significant injury occurred and resulted in the resident needing immediate medical attention. B. Review of an Incident Report dated 1/2/15 at 6:40 AM revealed Resident 14 was assisted to the toilet by a staff member. Documentation indicated the staff member turned to get something and the resident was discovered lying on the floor with their head under the sink and feet pointing towards the door of the bathroom. The resident sustained [REDACTED]. Review of Progress Notes revealed a late entry dated 1/2/15 at 6:40 AM which indicated Resident 14 was discovered lying on the bathroom floor. The resident complained of back pain and had a 1.5 centimeter (cm) laceration on the back of the head. The resident was transported to the emergency room for treatment. Documentation further indicated the resident returned from the emergency room at 10:00 AM that day after the laceration had been sutured (stitched). Review of the facility investigations of potential abuse/neglect from 1/1/15 through 12/10/15 revealed no report had been filed with the State Agency regarding Resident 14's fall on 1/2/15 which resulted in the need for immediate medical attention. There was no evidence to indicate an investigation had been completed or submitted to the State Agency. Review of an Incident Report dated 5/4/15 at 4:00 PM revealed Resident 14 was observed to have a dark purple bruise on the left side of the bottom lip which measured 3 cm by .6 cm. Review of an Injuries of Unknown Source Checksheet (undated) revealed an investigation was completed regarding the bruise on Resident 14's lip. Documentation indicated the resident was combative/resistive and was receiving medication that might potentiate bruising. Documentation further indicated no bruising was observed when the caregiver placed dentures in the resident's mouth that morning and the bruise was noted when the resident was gotten up after supper. The conclusion was the resident frequently refused care, was combative and would not always let staff put dentures in place. Documentation indicated abuse was not suspected as the resident could have bit self while asleep. Review of the facility investigations of potential abuse/neglect from 1/1/15 through 12/10/15 revealed no report was filed with the State Agency regarding the bruise on Resident 14's lip which was noted on 5/4/15. There was no evidence the results of the investigation were submitted to the State Agency. Interview with the Director of Nursing (DON) on 12/10/15 at 9:40 AM confirmed Resident 14's fall with injury on 1/2/15 was not reported to the State Agency and an investigation had not been completed. The DON confirmed the bruise on Resident 14's lip which was observed on 5/4/15 was not reported to the State Agency. The results of the facility investigation regarding the resident's bruised lip were not submitted to the State Agency. C. Review of Resident 18's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/25/15 identified the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The assessment further indicated the resident had severe cognitive impairment and required total staff assistance with activities of daily living. Review of Resident 18's Care Plan with revision date 11/25/15 revealed the resident had a history of [REDACTED]. An interview with Resident 18's family member on 12/8/15 between 10:56 AM and 11:20 AM, revealed the family member had previously voiced concerns to the DON regarding potential verbal abuse by a facility staff member. The family member was unaware of what action was taken by the facility regarding their concerns. Review of the facility investigations of potential abuse/neglect from 4/7/14 to 12/10/15 revealed no report had been filed to the State Agency regarding a potential allegation of staff to resident verbal abuse related to Resident 18. During an interview on 12/9/15 from 11:00 AM to 11:15 AM, the DON confirmed Resident 18's family member had reported to the DON they had received a call from the facility on 6/15/14. The family member indicated a message was left on their answering machine by Resident 18. A staff member was heard talking to the resident in the background telling Resident 18 to stop lying and to tell them what you did. The DON indicated Resident 18 was having behaviors at that time which included flipping off the staff and other residents and asking staff members inappropriate questions about their sex lives. When staff redirected the resident, the resident would become upset and frequently requested to call family. The DON stated the facility did not view the situation as a potential abuse allegation and verified no investigation was completed and no report was sent to the State Agency. 2019-07-01