cms_NV: 56
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
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rowid
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facility_name
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facility_id
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address
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city
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state
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zip
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inspection_date
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deficiency_tag
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scope_severity
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complaint
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standard
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eventid
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inspection_text
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filedate
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| 56 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2019-10-16 |
661 |
D |
0 |
1 |
LI3Z11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to complete a discharge summary by the primary care provider to include the recapitulation of the resident's stay and the treatment and services obtained at the facility for 1 of 2 sampled closed records (Resident #22). Findings Include: Resident #22 Resident # 22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Resident #22's Discharge Orders and Instructions Sheet lacked evidence of a physician's signature, diagnoses, recapitulation of the admission to include the course of treatment and services provided by the facility. The follow up care instructions documented call for appointment with physician contact information left blank. Resident #22's Nursing Progress Note, dated 09/26/19, documented by the Director of Nursing (DON), indicated the resident was discharged home and was to follow up with the physician. On 10/15/19 at 9:33 AM, the Unit Secretary confirmed Resident #22's clinical record lacked documented evidence of a complete Discharge Summary. On 10/15/19 at 9:44 AM, the Director of Nursing (DON) verbalized the facility lacked documented evidence of a complete Discharge Summary. On 10/16/19 at 9:29 AM, the DON confirmed Resident #22 was not provided a recap of the resident's admission or an explanation of the course of treatments and services provided at the time of discharge. The DON confirmed the family or resident's representative was also not given the documentation regarding the resident's admission. Resident #22's clinical record contained physical therapy notes to include a discharge summary, dated 09/25/19. The summary lacked the primary care provider's signature, follow-up care, and evidence the summary was provided to the resident or family member. On 10/16/19 at 9:31 AM, the DON confirmed the nursing staff did not provide the resident or family the discharge summary at discharge. The Doctor of Physical Therapy (DPT) signed the Physical Therapy Discharge Summary. The DON explained the DPT did not substitute as the Medical Provider as he is only one aspect of the resident's care. The DON verbalized the Medical Director (MD) was the Primary Care provider for the resident. The facility policy titled, Discharge of Resident, last revised 11/21/17, documented a resident may be discharged home only with permission of the attending physician unless the resident signed out against medical advise. Signed discharge orders and instructions will be obtained from the medical provider. A discharge summary must be accomplished by the medical provider within ten days after discharge. |
2020-09-01 |