cms_NE: 72
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 72 | HOMESTEAD REHABILITATION CENTER | 285049 | 4735 SOUTH 54TH STREET | LINCOLN | NE | 68516 | 2019-09-30 | 689 | D | 0 | 1 | UZYC11 | **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 failed to ensure that a fall event was documented and root cause analysis was completed for 1 resident (Resident 45) of 2 residents reviewed, and the facility failed to ensure residents were assessed for smoking safety on admission for 1 resident (Resident 6) of 2 residents reviewed. The facility census was 123. Findings are: An 09/25/19 at 12:30 PM of staff in the hallway addressing the w/c (wheelchair) for Resident 45 the NA reported that the they felt the back of the chair did not go back and the resident was at risk for a fall. RN V told the staff member to wait and get Resident 45 up later and set them at the table. A Record review of Fall Event - Altitude fall form dated 5/24/19 revealed; the document had not been completed. An interview on 09/26/19 at 01:14 PM with the CSC confirmed; that the fall event Altitude fall form had not been completed. Progress note IDT (Interdisciplinary Team) Risk Note dated 05/24/19 revealed; Resident 45 had a fall from the w/c (wheelchair), Resident 45 had pulled out call light from the wall and had self-transferred from the w/c to the bed. The alarm was not place back on the resident post therapy. The intervention: Resident 45 would have a safety alarm before and after therapy. Record review of Care Plan dated 05/01/2019 revealed; Resident 45 was at risk for falls due to: TODD paralysis (a paralysis is a neurological condition experienced by individuals with [MEDICAL CONDITIONS]([MEDICAL CONDITION] (Stroke)) and confusion. An intervention dated 05/24/19 for Resident 45 was to have alarm placed on wheelchair during all therapies. Occupational Therapy, Physical Therapy, Speech Therapy Approach Start Date: 05/24/2019 An observation on 09/26/19 at 1:00PM of Resident 45 seated at the table in a tilt in space w/c. Record review of Resident 45's MDS (Minimal Data Set an assessment used to assist in development of a comprehensive plan of care) Quarterly dated 9: Section C- revealed; Resident 45 was moderately impaired both short and long term memory. Section [NAME] revealed; No behaviors Section G revealed; Resident 45 required extensive assist with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Section H revealed; Resident 45 was always incontinent bowel and bladder. Section J Falls revealed; Resident 45 had falls since admission. Section O revealed; Resident 45 had not been in therapy. Section P revealed; resident 45 did not have alarms. B. Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 6 revealed that the resident is a current tobacco user with the potential for smoking related injury. Interventions on the care plan included that a Smoking Observation (an assessment to identify resident safety and interventions for smoking safety) be performed upon admit, quarterly, and as needed. Record review of the Electronic Health Record for Resident 6 revealed the completion of the Facility Smoking Safety Observation on 8/6/19. No other Smoking Safety Observations assessments were documented in the resident record. The Smoking Safety Observation dated 8/6/19 confirmed that Resident 6 is allowed for supervised group smoking only, including smoking apron and staff to light cigarette. Record review of the Resident Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 6 confirmed that the resident was admitted to the facility on [DATE]. Observation on 9/24/19 at 3:32 PM revealed that Resident 6 walked out into the facility courtyard. Certified Nursing Assistant (CNA) M handed a smoking apron (a protective cover to shield against hot ashes and dropped cigarettes) to Resident 6 and the resident put it on without assistance. CNA M handed a cigarette to Resident 6 and lit the cigarette for the resident. Interview with Resident 6 on 9/26/19 at 8:55 AM in the Lancaster dining room of the facility revealed that the resident came to the facility to live in (MONTH) of this year. Resident 6 confirmed that the resident was allowed to smoke from the time of admission to the facility. Observation on 9/26/19 at 9:47 AM in the facility courtyard revealed that Resident 6 was handed a smoking apron and a cigarette. CNA N then handed a cigarette lighter to Resident 6. Resident 6 lit the cigarette and then handed the lighter to CNA N. Interview on 9/26/19 at 9:47 AM with CNA N in the facility courtyard confirmed that Resident 6 lit his own cigarette and that the resident gave the lighter back right away. Interview on 9/26/19 at 10:44 AM with the Director of Nursing (DON) confirmed that Resident 6 was admitted to the facility on [DATE] and that the first and only Smoking Safety Observation completed for the resident was on 8/6/19. The DON confirmed that the facility Smoking Policy dated 8/17/19 directed that smoking risk observations are to be performed upon admission. The DON confirmed that the Smoking Safety Observation identified that Resident 6 required group supervised smoking only including a smoking apron and for staff to light the cigarette. | 2020-09-01 |