cms_OR: 42
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 42 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2017-09-26 | 225 | D | 1 | 0 | 5RH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to thoroughly investigate falls and complete investigations in a timely manner for 1 of 3 sampled residents (#5) reviewed for falls. This placed residents at risk for neglect of care. Findings include: Resident 5 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2016 Abuse/Neglect/Misappropriation/Exploitation policy indicated incidents were to be thoroughly investigated, staff were to ensure witness interviews were obtained and data collection was to be completed including care plan review. The policy directed staff to complete the investigation within five days of the incident. The 1/10/17 Admission CAAs indicated Resident 5 had dementia and a history of falls. The resident was assessed to have poor balance, weakness and was at a moderate risk for continued falls. The resident was also identified to be incontinent of bowel and bladder and did not always use the call light to request assistance. The current Care Plan indicated Resident 5 was incontinent and staff were to offer the resident toileting every two hours and the resident was to be assisted to the bathroom after meals and at bedtime. To prevent falls and injury the resident was to have interventions including a mat on the floor by the side of the resident's bed and the resident was to wear non-skid footwear. a. The 7/6/17 Fall investigation indicated Resident 5 fell at 8:55 am. The resident was found on the floor in the shower room located in the resident's room. The resident reported she/he wanted to take a shower. The CNA last observed the resident in the wheelchair in the front lobby by the television. The investigation did not address if the resident was assisted to the bathroom after breakfast as directed by the care plan. The investigation was not completed until 8/2/17, 27 days after the resident fell . On 8/29/17 Staff 1 (RNCM) acknowledged breakfast was from approximately 7:30 am to 8:30 am. The investigation did not indicate if the resident was offered toileting after breakfast. Staff 1 also acknowledged the investigation was not completed within 5 days. b. The 7/10/17 Fall investigation indicated Resident 5 was observed on the floor. The investigation indicated the resident was last seen sitting at the edge of her/his bed and the resident did not request assistance. The investigation indicated the resident did not have footwear in place and was a factor in the fall. The investigation was completed on 8/2/17, 23 days after the fall. On 8/29/17 at 9:40 am Staff 1 (RNCM) acknowledged Resident 1 was last seen at the edge of the bed and the investigation did not address the reason the resident did not have nonskid foot wear in place. Staff 1 also acknowledged the investigation was not completed five days after the fall. c. The 7/19/17 Fall investigation indicated Resident 5 fell at 4:20 pm. The resident was outside on the patio, the wheels of the wheelchair went of the walkway and the resident's wheelchair tipped. The investigation was not completed until 8/2/17, 14 days after the fall. On 8/29/17 at 9:40 am Staff 1 (RNCM) acknowledged the investigation was not completed within five days of the resident's fall. | 2020-09-01 |