cms_SC: 4

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

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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
4 BRUSHY CREEK POST ACUTE 425004 101 COTTAGE CREEK CIRCLE GREER SC 29650 2019-01-21 842 D 1 0 ZBYG11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to document in the resident's clinical record the nursing assessment of the physical condition for one of five residents reviewed for falls. (Resident (R) 2) after R2 fell from the mechanical lift to the floor. In addition, the facility failed to document the reason R2's physician was not notified for approximately one and one-half hours after the fall. Findings include: R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 24-hour Report dated 12/28/18 indicated the details of the incident that occurred on 12/27/18 at 7 PM, Resident was in Hoyer lift being placed back to bed. Hoyer lift clip cracked, and resident fell to the floor from an up position to her/his left side . Resident was sent to the ER. Review of R2's Progress Notes dated 12/27/18 at 2240 (11:40 PM) indicated, While CNA (certified nurse aide) was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . Resident requested to be sent to ER( emergency room ) . PCP (primary care physician) notified at 2034 (8:34 PM) and informed of incident and request to send to ER. EMS (Emergency Medical Services) arrived at 1906 (7:06 PM). Substitute POA (Power of Attorney) notified at 2234 (10:34 PM). Review of the document titled PACS Nursing - Post Fall Review, dated 12/27/18 at 6:50 PM, addressed that there was no history of falls; the medication the resident received were narcotics, diuretics, and laxatives; memory cognitively intact; adequate vision; total incontinence of urine and bowel movement; no behaviors in last seven days; confined to chair; no problems with blood pressure; and gait indicated unable to independently come to a standing position. The document did not document the physical assessment of R2 when s/he was observed on the floor after the fall from the mechanical lift. The document did not identify who was the writer of the document. Review of the document titled PACS: Nursing-Body assessment, dated 12/27/18 at 7 PM, indicated Body assessment - Skin condition hematoma back of head and complaint of pain to L (left) leg. There was no further documentation on this document nor whom was the writer of the document. Review of a document titled Witnessed Fall, completed by Licensed Practical Nurse (LPN) 5 dated 12/27/18 at 6:50 PM indicated Incident Description - While CNA was transferring the resident to bed via hoyer lift, upon placing the hoyer lift in the upright positions, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. The Patient stated the sling broke and I fell out onto the floor. Immediate Action Taken - Resident was assessed . Injury type - Hematoma/Bruise back of head, alert, oriented to place time, person and situation. Review of a document titled Health Status Note, dated 12/27/18 at 10:49 PM. indicated While CNA was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . sent to ER . PCP notified at 2034 (8:34 PM) . EMS arrived and transported resident at 1906 (7:06 PM). Review of the undated facility's policy titled, Falls-Clinical Protocol indicated, 5. The staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observation of the events, etc. During an interview on 01/21/18 at 1 PM with the Administrator and Assistant Director of Nursing (ADON), the Administrator stated that s/he was unable to locate any further documentation regarding the physical assessment of R2 after s/he fell to the floor from the mechanical lift on 12/27/18 at 7 PM. The Administrator and ADON stated that it was their expectation that nurses document their assessment of the resident after a fall. The Administrator confirmed that s/he had no explanation, nor could s/he find any documentation why the PCP was not notified until 8:34 PM (almost one and one-half hours after R2 was transported to the ER). 2020-09-01