cms_NE: 850

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.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
850 MONUMENT REHABILITATION AND CARE CENTER 285095 111 WEST 36TH STREET SCOTTSBLUFF NE 69361 2019-05-28 689 G 0 1 3V0011 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews and interviews; the facility failed to ensure that 1) safety measures were in place to prevent one sampled resident (Resident 44) from falling during bathing. The failure resulted in the resident sustaining a fracture; 2) care plan interventions were in place to reduce the risk for recurrent falls for one current sampled resident (Resident 41); and 3) a loose grab bar was secured to the bed frame to reduce the risk for injuries for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Interview with Resident 44 on 5/22/19 at 1:45 p.m. revealed the resident describing having sustained a fall and fracture requiring surgery and hospitalization about a month after being admitted . The resident described the incident by stating the fall occurred in the tub room after the bath was completed. The resident stated being in a bath chair and that Usually the staff strapped the resident in the chair and had a second person present during transfers. On this occasion, the staff did not apply the strap or have a second person present. The resident described tumbling out of the chair and fracturing a leg resulting in the need for surgery after being diagnosed with [REDACTED]. Record review of Resident 44's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed an Admission assessment was completed on 2/20/19. The assessment recorded the following items regarding the resident's condition: - The assessment recorded the resident was admitted from another nursing home on 2/14/19. - The assessment recorded a resident BIMS (Brief Interview for Mental Status) test score was 15 (cognitively intact memory). - The assessment recorded the resident's ability to transfer between surfaces (to and from bed, chair, wheelchair) required the assistance of Two (or more) and that the resident required Total dependence- full staff performance to complete transfer tasks. -The assessment recorded the resident required Two (or more) persons and Physical assist support for Bathing. - The assessment recorded the resident's weight at the time of the assessment was 355 pounds. - Under the fall history portion of the assessment the facility recorded the resident had a history of [REDACTED]. Record review of Resident 44's electronic Progress Notes revealed the following entry: - 3/6/19 at 5:50 p.m. the note recorded a Situation while the resident was transferring during bath and fell to floor. The note recorded the resident was being transferred during a bath and was in bath chair. Is a bariatric (obese) patient. The note recorded the resident was assessed and assisted to a comfortable position and that the resident complained of Left hip pain. The medical provider was called and an order received to transfer the resident to the emergency room for evaluation. Record review of a hospital History and Physical Reports form dated 3/6/19 revealed the resident's CC (chief complaint) at the time of admission was I fell getting out of the bathroom. The physical recorded the resident was sent from the facility today after falling getting out of the bathroom, landed on left side, and ER (emergency room found to have left displaced femur fracture. The physical assessment diagnosed : Left femur fracture. Record review of a facility undated New ownership investigation of Resident 44's fall on 3/6/19 revealed a nurse was called to the 100 wing tub room and observed resident on floor between tub and north wall. The resident was sitting up with head against the tub, left leg straight out and right leg was bent. The resident expressed pain to the left leg. An ambulance was called and the resident transferred to the emergency room . The BA (Bath Aide)-W was interviewed during the investigation and re-enacted the incident. The investigation recorded the resident bath was completed and BA-W took off the resident's strap to clean under the abdominal folds and then elevated the tub chair to get the resident's feet out of the tub and pulled the chair out of the whirlpool When getting the resident out of the tub chair to put the belt back on the resident leaned forward and fell out of the tub chair. The investigation report indicated the resident was interviewed and stated remembering the bath aide having to jerk the tub chair and I flew out of the chair. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 5/28/19 at 10:39 a.m. verified Resident 44 sustained a fall and fracture during the bathing process on 3/6/19. The DON and ADON verified there was only one staff member assisting the resident during the bath and the transfer out of the tub. The causal factor for the fall was verified as the removal of the seat belt strap by BA-W while assisting the resident out of the tub. The failure to apply the strap resulted in the resident falling forward and sustaining the injury. The DON and ADON stated that safety straps should not be removed during the bathing procedures. B. Review of Resident 41's Care Plan, goal date 6/3/19, revealed that the resident was at risk for falls due to history of falls and the resident was found on the floor by the bed on 4/16/19. Further review revealed interventions including staff will ensure that the resident's bed was left in the low position while the resident was in bed and the call light was within reach at all times when in the room. Observations on 5/22/19 at 5:00 AM revealed Resident 41 resting in bed with eyes closed. Further observations revealed that the bed was positioned approximately waist high and the call light was fastened to the connection on the wall and not within the resident's reach. Interview on 5/22/19 at 5:10 AM with LPN (Licensed Practical Nurse) - G, Charge Nurse, confirmed that the resident's bed was to be left in the low position and that the resident was to have the call light within reach to reduce the risk for falls. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the staff were to follow the care plan interventions to reduce the risk for falls. C. Review of Resident 42's Care Plan, goal date 6/18/19, revealed that the resident required staff assistance with bed mobility and that the resident utilized assist rails on the bed for repositioning. Observations on 5/20/19 at 9:10 AM revealed the assist rail on the open side of the bed was loose and presented a three to four inch gap between the assist rail and the airflow mattress. Interview with the DON on 5/21/19 at 3:50 PM confirmed that the assist rail needed to be tightened to the bed frame to reduce the risk for injuries. 2020-09-01