cms_OR: 22
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 |
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22 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2018-10-29 | 610 | D | 1 | 0 | O7YK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to immediately initiate an investigation when a bruise of unknown origin was identified for 1 of 3 sampled residents (#1) reviewed for injury of unknown origin. This placed residents at risk for neglect of care. Findings include: Resident 1 was admitted to the facility in (YEAR) after the surgical repair of a [MEDICAL CONDITION]. The Admission Nursing Data Base dated 9/20/18 indicated Resident 1 was admitted to the facility from the hospital after surgical repair of the right hip. The resident was identified to have bruises to the arms and a skin tear to the abdominal region. The Progress Notes indicated on 9/28/18 the resident was identified to have a new bruise to the right thigh. The note indicated the bruise was light purple and approximately seven cm by eight cm. The note revealed the resident's family was aware of the bruise. The Skin Impairment investigation was initiated on 10/1/18, three days after the bruise was identified. The investigation indicated the resident's family assisted the resident to use the bathroom. The family member showed the nurse a bruise to the right inner thigh. The bruise was faded purple, giving it an older bruise appearance. The resident denied pain when the bruise was palpated. The resident was not aware of how the bruise occurred. The investigation indicated the bruise was not reported to Staff 4 (RNCM) for three days. The investigation further indicated the resident was on a blood thinner and may have sustained the bruise when she/he sat on the toilet. The bruise was in the approximate location of the toilet seat edges. The resident was also identified to have 1:1 staff after admission to the facility related to the resident's poor safety awareness. The 1:1 staff were interviewed and the staff reported no falls or incidents which may have caused the bruise. The physician was notified of the bruise on 10/1/18. On 10/19/18 at 1:10 pm Staff 5 (RN) stated he worked the day the bruise was identified on Resident 1's inner thigh. First thing in the morning on 9/28/18 the resident's family was in the resident's room and assisted the resident to the bathroom. The family member showed Staff 5 the bruise to the inner thigh. Staff 5 stated he did not see the bruise prior to 9/28/18. Staff 5 indicated the resident was able to report pain and when he palpated the bruise the resident denied pain. Staff 5 stated he was a new nurse, documented the bruise in the Progress Note but did not initiate an incident report or report the bruise to Staff 4 (RNCM). On 10/19/18 Staff 4 stated the bruise to Resident 1's right inner thigh was identified on Friday and was not reported to her until Monday; therefore she did not start her investigation until three days after the bruise was identified. Refer to F-580 for additional information. | 2020-09-01 |