cms_OR: 13

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
13 LAURELHURST VILLAGE 385010 3060 SE STARK STREET PORTLAND OR 97214 2018-06-01 609 D 1 0 4O6P11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to report potential neglect of care to the state agency for 1 of 3 sampled residents (#1) reviewed for falls. This put residents at risk for potentially avoidable incidents. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on 5/3/18 which indicated the resident was left unattended on the bedside commode and fell . Witness 1 (Complainant) indicated the resident previously experienced a fall at her/his memory care facility and sustained a [MEDICAL CONDITION]. Witness 1 stated within three hours at the facility the resident was left on the bedside commode, fell and sustained a 2-3 inch laceration which required stitches. A nursing facility form labeled HOSPITAL REPORT dated 4/14/18 at 3:30 PM indicated the resident had a right [MEDICAL CONDITION], was forgetful with dementia and had mixed continence/incontinence. The resident was noted to be weight bearing as tolerated and required two person transfer assistance to the commode. A hospital discharge summary dated 4/14/18 indicated the resident had severe dementia and previously resided in a memory care facility where she/he sustained a fall with a resulting [MEDICAL CONDITION]. The resident stabilized and was discharged to a skilled nursing facility for continued physical therapy with the plan to return to her/his previous memory care facility. A facility admission nursing data base with an effective date of 4/14/18 indicated the resident was oriented to person and lethargic. The resident's prior level of function was marked as dependent and admitted related to a ground level fall with a [MEDICAL CONDITION]. The assessment indicated the resident had three falls in the last month and 4-5 falls in the last six months per the resident's family. A facility incident investigation dated 4/14/18 at 7:41 pm indicated the resident fell from the bedside commode and cut her/his head. The resident was observed attempting to self transfer out of the bed and Staff 4 (CNA) assisted the resident to the bedside commode at her/his request. Staff 4 left the room to get clean bedding for the resident and when he returned the resident was on the ground and other staff were present. A witness statement from Staff 4 stated he gave the resident the call light and told her/him not to transfer back to bed until he returned. The investigation indicated no abuse or neglect was suspected. A comprehensive care plan dated 4/16/18 and an undated Kardex (CNA care plan) indicated the resident required two person assistance for transfers and toileting. No care plan information prior to 4/16/18 was located. Interview on 6/1/18 at 11:20 am Staff 2 (DNS) indicated the resident's fall was not reported to the state agency. Interview on 5/31/18 at 9:20 am Staff 4 (CNA) indicated he was not familiar with the resident or her/his care plan at the time of the fall. Staff 4 stated he did not check the care plan as he was in a hurry. When he entered the room the resident was already trying to get out of bed. Staff 4 offered the resident the bedpan but the resident requested the bedside commode. Staff 4 assisted the resident to the commode and then left the room for just a moment to get new bedding. Staff 4 stated he should have checked the care plan and stayed with the resident because he was not familiar with the resident. Staff 4 thought the resident would be ok for a few minutes. Interview on 6/1/18 at 12:12 pm Staff 5 (RN) indicated 4/14/18 was a very busy day with multiple admissions; Resident 1 admitted later in the day. She heard a loud noise and headed to the resident's room. The resident was on the floor with her/his brief around her/his knees and was found to have a wound to the back of the head. Staff 5 stated the physician was notified, the resident was sent to the hospital for evaluation and returned to the facility a few hours later with staples in place. Staff 5 stated prior to the resident's admission the hospital reported the resident was oriented only to person and had a [MEDICAL CONDITION]. The hospital did not report any behaviors. Staff 5 further indicated she was working on other admissions and had not interacted with the resident at all prior to responding to the resident's fall. Staff 5 stated when a new admission came in she normally reported the resident's basic information such as orientation, transfer status, continence and any other safety items to the charge nurse and CNAs prior to the resident arriving at the facility. Staff 5 was unsure if her reports regarding the resident were passed on to the evening shift staff. Staff 5 indicated the resident should not have been left alone on the bedside commode based on her/his orientation status and [MEDICAL CONDITION]. Refer to F-689 2020-09-01