cms_OR: 14

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

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
14 LAURELHURST VILLAGE 385010 3060 SE STARK STREET PORTLAND OR 97214 2018-06-01 689 G 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 ensure a resident received adequate supervision to prevent a fall 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, sustained a [MEDICAL CONDITION] and was hospitalized . The resident was discharged from the hospital to the nursing facility. Witness 1 stated within three hours of admission to the nursing 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 the resident was 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 the resident's 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. The resident's care plan dated 4/16/18 indicated the resident had an ADL performance deficit related to confusion, dementia and musculoskeletal impairment. The resident required two staff assistance to use the toilet and to transfer. The resident was noted to have experienced an actual fall with serious injury. The resident was noted to have a recent [MEDICAL CONDITION] and a history of falls. The resident's undated kardex (CNA care plan) indicated the resident was not to be left unsupervised in the bathroom or on the bedside commode, keep the bed in the locked position at all times and the resident was to wear non-skid foot wear at all times. The resident required two staff assistance for transferring, mobility and toilet use. No care plan information prior to 4/16/18 was located. A hospital after visit summary dated 4/14/18 indicated the resident was treated for [REDACTED]. The resident was started on antibiotics for the UTI and had three staples in place to the [MEDICAL CONDITION]. The resident's staples were to be removed in 10-14 days. The resident's (MONTH) (YEAR) MAR indicated [REDACTED]. No medications were documented on 4/14/18. The resident received one dose on 4/15/18 for a pain level of 3, two doses on 4/16/18 for a pin level of 7 in the morning and a pain level of 4 in the early evening. The resident continued to receive one dose of [MEDICATION NAME] each day for pain level varying from 5-9. The resident's pain was rated on a pain scale of 0-10, 0 being no pain and 10 being extreme pain. A nursing progress note dated 4/14/18 at 1:20 PM indicated the resident was admitted with a [DIAGNOSES REDACTED]. The resident's prior level of function was dependent. The resident arrived via a wheelchair and was transferred with the assistance of two staff. The resident was oriented x1 (person) had adequate hearing and clear speech. The resident was additionally noted as always incontinent of bowel and bladder. A nursing progress note dated 4/15/18 at 7:19 AM indicated the resident was admitted on late evening shift; initial contact with the resident was following a fall at 7:40 pm on 4/14/18. The resident was found on the floor on her/his back after attempting to get up form the commode without assistance. The resident sustained [REDACTED]. Interviews conducted 5/31/18 through 6/1/18 between 8:30 AM and 1:30 PM showed: 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. When he returned the resident was on the ground and other staff were present. 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. Staff 7 (RNCM) indicated the resident arrived late in the day and it was determined the report from the hospital was not an accurate picture of the resident. The resident's care plan was not done within the first 24 hours which was their rule of thumb; the care plan information was all dated 4/16/18. Staff 7 stated it appeared both admission nurses completed the resident's admission which was not the normal procedure. Staff 4 (CNA) did not have a good understanding of the resident and after putting the resident on the bedside commode he left the room and the resident fell . Staff 7 indicated when the resident returned from the hospital, after the fall, a sitter was instituted to stay with the resident at all times. The resident was more confused, combative and made repeated attempts to get up on her/his own. Staff 7 was not sure what happened with the initial care information for the resident. Staff 6 (RN) indicated he had no interaction with the resident prior to the fall on 4/14/18. Staff 6 stated he had not received any information or reports about the resident and was unsure how long the resident was at the facility prior to the fall. CNA staff came and reported the resident was on the ground so he went to assess the resident. The resident's vital signs were stable but did have bleeding from the back of her/his head. Staff 6 was concerned about a bleed so the resident was sent to the hospital for a CT scan and evaluation. The resident returned to the facility several hours later with staples in place to the back of her/his head. Staff 8 (RN) indicated he was not working at the time the resident was admitted on Saturday 4/14/18. When he returned on 4/15/18 he was told the resident's admission needed to be completed so he finished the needed items. Staff 8 stated the resident answered questions but seemed confused so he contacted the resident's son for much of the information. Staff 5 (RN) indicated 4/14/18 was a very busy day with multiple admissions; Resident 1 admitted later in the day but she could not remember exactly when. 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 did not interact with the resident prior to responding to the resident's fall. Staff 5 stated when a new admission was scheduled 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]. 2020-09-01