cms_NE: 63
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 63 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 600 | D | 1 | 1 | UZYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175NAC 12-006.05 (9) Based on record review, observation, and interview the facility failed to ensure that residents were kept free from abuse resulting in an injury for 1 resident (Resident 87) of 1 resident reviewed, and the facility to report misappropriation of medications for 2 residents (Resident 326 and 333). The facility census was 123. Findings are: [NAME] Record review of the facility policy titled Abuse Prevention Program dated (MONTH) 2006 revealed: Preventing Abuse Step 1: Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Preventing Abuse Step 3i: The implementation of changes to prevent future occurrences of abuse. Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the Progress Notes and the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 87 revealed no documentation of facility measures to protect the resident from resident to resident abuse. B. Record review of an APS (Adult Protective Services) report dated 07/01/19 revealed; an anonymous reporter reported that Resident 326 was discharged to home on a Friday. Resident 326 had been picked up by a friend, and asked the MA (Medication Aide) if they could speak with the nurse for instructions for the medications and discharge instructions. Resident/Resident friend was told that the nurse was not available, the mediations were bagged and ready to go. Resident 326 and friend went to HyVee pharmacy to get instructions. The pharmacist reported that the bagged medications were not the Resident 326's medications. The Reporter told APS that the medications belonged to Resident 333. The caller reported that the facility was called, spoke to SSD asked that the medication be brought back to the facility. The caller reported that the facility staff was to go the pharmacy and pick up the medications. Record review revealed; no facility self-report of misappropriation of medication for Resident 333 that were sent home with Resident 326. Record review of Resident 326's medications revealed; [MEDICATION NAME] 10 mg (milligrams) tablet one daily 0800 Fish oil 1000 mg 120mg-180mg daily 0800 [MEDICATION NAME] 0.4 mg daily 8PM [MEDICATION NAME] 88 mcg daily 0500 [MEDICATION NAME] 3.4/5.4 gram 1 packet daily 0800 [MEDICATION NAME] 40 mg BID (Twice a day) 0730/3:30PM [MEDICATION NAME] (Vitamin B6) 25 mg 1 tab 0800 [MEDICATION NAME] XL 25mg 1 tab daily 0800 Vitamin D 3 1 tablet daily 0800 [MEDICATION NAME] 1 gr QID (four times a day) 0800/1200/4:00P/8:00P Record review of Resident 333 medications revealed; [MEDICATION NAME] 200mg 1 tablet once a day at 0800 ASA 81 mg daily 0800 [MEDICATION NAME] 150 mg once a day at the 1st of the month 0800 [MEDICATION NAME] Fiber Singles BID Multivitamin with minerals 1 tab daily Pantoprazole 1 tab once a day 0800 Potassium chloride 10 MEQ (Millaequivalent) 1 cap daily 0800 Requip 4 mg BID 0800/8:00PM [MEDICATION NAME] 100mg 1 tablet daily 0800 [MEDICATION NAME] HFA 160-4.5 Mcg 2 puffs Rinse after use- 0800/8:00PM Mag oxide 400 mg 1 tab TID 0800/1:00PM /6:00PM [MEDICATION NAME]-[MEDICATION NAME] 5/325mg 1 tab QID 0800/1200/4:00PM/8:00PM An interview on 09/25/19 at 03:05PM with the CSC confirmed; that Resident 326 was sent home with another residents medications. Both Resident 326 and 333 had medications bagged for home and the nurse grabbed the wrong bag of medications. The CSC reported that the nurse on duty was to have disciplinary action by the Unit Manager and there was no documentation that the discipline had been completed. The nurse manager was sent to Hy Vee and retrieved the medications and the residents correct medications were delivered to the resident at the place of discharge. The Unit Manager was no longer employed. The nurse who gave the medications to Resident 326 was no longer employed. The CSC confirmed; that the facility had not reported the incident. | 2020-09-01 |