cms_PR: 58

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.

Data source: Big Local News · About: big-local-datasette

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
58 DAMAS HOSPITAL SNF 405023 2213 PONCE BY PASS PONCE PR 717 2017-05-25 514 F 0 1 NJQB11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a standard and extended FOSS survey conducted on 5/22, 5/23, 5/24, and 5/25/17 for recertification, five records review (RR), and review of policies and procedures (P&P's), it was determined that the facility failed to maintains accurate, complete and organized clinical information about each resident, as observed in 1 out of 7 records reviewed (RR #5). Findings include: 1. Resident #5 is a [AGE] years old Female admitted on [DATE] with a [DIAGNOSES REDACTED]. During the record review performed on 5/22/17 at 2:00 pm it was found the following: a. The physical therapy progress note of 2/11/17 was not counter signed by the physical therapist. b. During review of the occupational therapy progress notes from 2/24/17 and 3/11/17 were not signed. c. During review of the occupational therapy progress notes from 3/3/17 documented that the patient had pain however did not documented the pain scale. d. During review of the physician medical orders a telephone orders was place on 2/9/17 at 5:00 pm and was signed by the physician on 2/10/17; however the physician did not include the time in which the telephone order was signed. During P&P's review related to Medical Orders in the skilled nursing facility on 5/22/17 at 2:30 pm was found evidence that item #1 states: 1. Telephone and verbal orders are accepted, they are to be signed by the physician during the 24 hour period since the order was made. The facility failed to ensure that the physician staff include the time in which the telephone order was signed to certify that was on the 24 hour timeframe. e. During review of the graphic sheets of 2/3/17 thru 3/6/17 was found evidence that the nursing staff failed to document the resident's weight. On the Weight Sheet Registry form was documented on 2/28/17 that the resident's weight is 128.6 pounds. However there is no evidence that the resident's weight was re-assessed. During P&P's review related to Weight assessment in the skilled nursing facility on 5/22/17 at 2:30 pm was found evidence that item #10 and #11 states: 10. Once the resident is admitted to the unit, the initial weight of the resident will be taken and documented in the nursing profile, the weekly weight on the weight record sheet. 11. If the resident refuses or cannot be weighed, documentation will be done on the weight record sheet. The resident will be heavy every Tuesday, and the weight should be documented on the weight record sheet the same day the weight is taken. However the facility failed to ensure that nursing staff perform and documents the weekly weight assessment according to facility's P&P's. f. During review of the Nursing Initial Assessment of 2/3/17 at 7:30 pm was found evidence that the height of the resident was not documented. g. During review of the Nursing progress notes was found the following: (i) Nursing note of 2/6/17: Skin care: Yes Skin appearance: Normal Skin integrity: Altered Wounds: Extremities Appearance: Close, dry, and granulating (ii) Nursing note of 2/7/17: Skin care: No Skin appearance: Normal Skin integrity: Altered Wounds: Hip Appearance: Close, dry and granulating (iii) Nursing note of 2/10/17: Skin care: No Skin appearance: Normal Skin integrity: Altered Wounds: Extremities Appearance: Close, dry and granulating There is inconsistency in nursing documentation related to whether or not the resident receives skin care and the location of the wound. During interview with the Administrative Supervisor (Employee #3) on 5/22/17 at 2:00 pm, she stated: There is incongruence on the nursing progress notes of 2/6/17, 2/7/17, and 2/10/17. The nursing staff will be re oriented of documentation related to skin care. The facility provides constant in-services related to documentation, ulcer classification, and other topics. 2020-09-01