{"rowid": 1, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2018-03-29", "deficiency_tag": 565, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "XF2S11", "inspection_text": "Based on observation and interview the provider failed to ensure: *Meals were served on time for two of two observed meals in the main dining room. *Residents were aware of alternative meal options in one of two dining rooms (main dining room). Findings include: 1. Interview on 3/26/18 at 4:45 p.m. with the administrator revealed the meal times were: *In the rehabilitation (rehab) dining room breakfast was served at 7:30 a.m., lunch at 11:30 a.m., and supper at 5:30 p.m. *In the main dining room breakfast was served at 8:00 a.m., lunch at 12:00 noon, and supper at 6:00 p.m. Surveyor Observation on 3/26/18 from 5:54 p.m. through 6:30 p.m. in the main dining room revealed: *At 6:11 p.m. the serving window was closed. -No meals had been served yet. *At 6:15 p.m. the serving window opened, and the first tray was served. -An unidentified resident refused the tray and asked for soup. --She kept the bread and fruit. -Three out of four of the residents at the same table refused their tray and only took the fruit. Observation and interview on 3/27/18 from 6:13 p.m. through 6:20 p.m. in the main dining room revealed: *At 6:13 p.m. the serving window was opened. -The kitchen had not started serving. *Interview at 6:15 p.m. with licensed practical nurse D regarding resident choices for meals revealed: -They did not ask the residents prior to the meal as to what they would like to eat. -He stated We tried that once and it didn't work. -He said A resident would order fish for supper and then once supper came they would be like I don't want fish, and the server would say Yes you ordered this at breakfast today, and the resident would be like, No I don't want it, I want something else. -He thought it worked better now. --They just took the tray with the main menu meal option and if they did not want it they offered the alternative. *At 6:19 p.m. the serving window opened. *At 6:20 p.m. the first tray was served. Interview with a resident representative revealed: *Supper is routinely not served until 6:20 p.m. or 6:30 p.m. -Supper time was 6:00 p.m. *The resident would request to go back to her room before she received her meal. -He waits till 6:20 p.m. or 6:30 p.m. to take her to supper in hopes they have started serving supper. Surveyor Confidential interview on 3/28/18 at 9:30 a.m. with a group of residents revealed: *They had not gotten choices for meals. *They would be served the main meal option, and if they had not wanted it they would be told what the alternative was and could choose then. -They did not know the alternative options until they turned down the main item. *They would have liked to had choices and had the alternatives posted on the menu. *If they did not want the main dish, alternative meal option, or soup then they had to wait until the rest of the residents were served. *They were not able to recall a time the staff had asked them what they wanted prior to meal services. *The meal was never served at 6:00 p.m. -It was usually 6:20 p.m. or 6:30 p.m. before it was served. *They would like the meal to have been served at the scheduled time. Interview on 3/28/18 at 2:43 p.m. with the administrator regarding meal service revealed and confirmed: *They had complaints of beverages being served warm, so they had changed that system. *The meal was served late due to the change in the beverage system. *She knew the meals were not served on time. *Residents had not gotten a choice for their meals until they refused the main meal item. *The alternative meal option was not listed on the posted menu.", "filedate": "2020-09-01"}
{"rowid": 2, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2018-03-29", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "XF2S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to update and revise care plans for 3 of 18 sampled residents (8, 28, and 60). Findings include: 1. Review of resident 60's medical record revealed she had developed a pressure ulcer to her left heel on 3/12/18. Her care plan had not been updated to reflect that information. Refer to F686, finding 1. 2. Review of resident 8's 12/5/17, 2/14/18, and 3/16/18 care plans for skin integrity and pressure ulcers revealed a gap in documentation with no preventative interventions for a resident with a history of pressure ulcers. Refer to F686, finding 2. 3. Review of resident 28's undated care plan revealed she: *Was admitted on [DATE]. *Had two hospitalization s, and her last readmitted was 1/31/18. *Had focus areas for: [MEDICAL CONDITION], anticoagulant therapy, insulin r/t (related to) diabetes, diuretic therapy r/t heart failure, and respiratory distress. *Interventions and tasks such as: -Labs as ordered. -Monitor blood sugar, lab results as ordered by physician. -Administer medication pre physician orders. --Interventions and tasks were not resident specific. --Did not have adequate information to provide interventions and methods to monitor above areas. 4. Interview on 3/29/18 at 7:50 a.m. with the minimum data set (MDS) nurse regarding care plans revealed: *The initial care plan was created from the nurses admission assessment. *The first of the year they had started a new process with the care plans where if a resident was admitted and then discharged upon return to the facility, the care plan had to be completely regenerated. -Previous to the first of the year the care plan could be used from before. *The nurses were not comparing the previous care plan to the current care plan. -Interventions and tasks had not been brought forward. -Care plans were not complete. *She stated resident 25's care plan would be corrected today. *She had been reviewing them upon quarterly review, resident 25 had been in and out of hospital, so her care plan had not been reviewed at this time. *She agreed the areas of insulin/diabetes, anticoagulant therapy, cardiac diagnoses, and respiratory distress did not have adequate information to provide interventions and methods to monitor those areas. Surveyor: Review of the provider's (MONTH) (YEAR) Interdisciplinary Care Planning policy revealed: *The patient's (residents) care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. *It also identifies the types of methods of care that the patient should receive. *The care plan should focus on: -Preventing avoidable declines in function. -Managing patient risk factors. -Preserving and building on patient's strengths. -Patient's goals and individualized preferences. -Evaluating care and progress toward goals. -Respecting the patient's right to decline treatment. -Using an interdisciplinary approach. -Involving the patient and family. -Planning to care to meet the patients needs. -Involving direct care staff. *The care plan should: -Include patient-specific measurable objectives and time frames. -Include collaboration with other agencies that provides services to the patient (i.e. hospice or [MEDICAL TREATMENT]) including who provides that service. -Describe the services that the facility is to provide. -Describe any services that the patient should have, but refuses.", "filedate": "2020-09-01"}
{"rowid": 3, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2018-03-29", "deficiency_tag": 686, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "XF2S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and guideline review, the provider failed to ensure interventions were in place for two of three sampled residents (8 and 60) who developed pressure ulcers. Findings include: 1. Interview on 3/27/18 at 2:11 p.m. with licensed practical nurse (LPN) [NAME] and the administrator regarding the list of residents with pressure areas revealed: *Three out of the seven residents had suspected deep tissue injuries (SDTI). -If the area was deep purple or the blister was blood filled, it would indicate it was a deep tissue injury. *The Braden Risk Assessment tools were completed on the computer. *The Pressure Ulcer Scale for Healing (PUSH) tool was completed on paper. *The registered nurses staged the skin areas. *They had identified resident 60's left heel had a SDTI due to the blister being filled with blood. Observation and interview on 3/27/18 at 2:38 p.m. with LPN D and the director of nursing (DON) revealed: *They were completing a dressing change to resident 60's left heel. *The resident was sitting in her wheelchair. *She had a wound vac on the outer side of her left foot. -They were not to do anything with that at that time, as she had just returned from an appointment for it. *The orders were for a foam dressing and [MEDICATION NAME]. *She had a heel protector on her left foot. *The SDTI was approximately the size of a quarter. -It was unopened but dark purple and black in color. *It had developed while she had been a resident in the facility. Observation on 3/27/18 at 4:15 p.m. of resident 60 revealed she was in her room visiting with a visitor. She was sitting up in her wheelchair. Observation on 3/27/18 at 5:14 p.m. of resident 60 revealed she was propelling herself in her wheelchair going to the dining room. Observation on 3/28/18 at 8:39 a.m. of resident 60 revealed she was in therapy. Review of resident 60's medical record revealed: *Her admitted had been 1/17/18. *Her [DIAGNOSES REDACTED].>-Personal history of [MEDICAL CONDITION]. -Unspecified injury of unspecified kidney, initial encounter. -Other [MEDICAL CONDITION]. -Charcot's arthropathy. -[MEDICAL CONDITION], stage 4. -Acidosis. -[DIAGNOSES REDACTED]. -Mantle cell [MEDICAL CONDITION], unspecified site. -Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. -[MEDICAL CONDITION], unspecified. -Diabetes mellitus due to underlying condition with diabetic [MEDICAL CONDITION], unspecified. *Upon admission she had the following skin concerns: -Coccyx: opened area 3 centimeters (cm) x (by) 2.5 cm. -Groin: redness. -Left groin: pin point incision 0.1 cm x 0.1 cm. -Bottom left ulcer: 5 cm x 2 cm x 1.5 cm. -Right foot: lateral aspect, excoriated area 8 cm x 2.2 cm. Review of resident 60's 1/24/18 Braden Scale for Predicting Pressure Sore assessment revealed her score had been seventeen indicating she was at risk for developing pressure ulcers. Review of resident 60's undated care plan revealed interventions for the current left foot ulcer and for potential skin breakdown had been: *Nutrition supplements two times per day initiated on 1/24/18 and revised on 3/11/18 by the registered dietician. *Administer treatment per physician's orders. *Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn (as needed) initiated on 1/17/18. *For wound care, treat wound as needed. Currently had maggot therapy with nursing staff to reinforce dressing as needed only, initiated on 2/22/18. *Encourage to reposition as needed, use assistive devices as needed, initiated on 1/17/18 and revised on 3/13/18. *Pressure redistributing device on bed/chair per facility protocol, initiated on 3/13/18. *Provide preventative skin care routinely and prn, initiated on 3/13/18. *They had been no interventions for the left heel pressure ulcer or the use of the heel protector. Interview and record review on 3/29/18 from 8:58 a.m. through 9:35 a.m. with LPN [NAME] and the DON regarding resident 60 revealed: *The left heel pressure ulcer or SDTI had developed on 3/12/18. *They thought it had developed because her heel rested on the foot pedal. -She had to hold her foot at a different angle due to the wound vac on the side. *She had not had a heel protector on at that time. -She had worn a gripper sock on that foot. -The heel protector had been initiated after the left heel pressure ulcer had been found. *She was not one to lay down throughout the day and was very active. *A progress note indicated the physician had been notified, but there were no physician's orders in her record. *At 9:32 a.m. we went into LPN E's office for her to look as she thought she remembered writing it down. -She could not locate the physician's order for treatment. -The DON stated the process was to write the phone order, put it in the resident's chart, and send off the part to the doctor to have it signed. -They could not find that part. *The left heel pressure ulcer had not been on the care plan. -They both agreed it should have been. 2. Interview on 3/27/18 at 10:22 a.m. with resident 8 revealed: *She knew she had a bedsore on her backside. *She did not know why it had developed. *There had not been any pain. -It had caused her pain once when the adhesive from a dressing was being removed. *She was mostly numb from the waist down; not a new condition. -Staff were aware that she had limited sensation from the waist down. *She was able to readjust herself in her wheelchair, but she forgot because it did not hurt. -Staff did not remind her to readjust herself. -She was able to demonstrate how she could reposition herself but stated that if she were to lean too far forward she would lose control of her upper body and fall out of her wheelchair. Review of resident 8's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. -Early onset cerebellar ataxia. -Muscle weakness. -Need for personal care. -Unspecified dorsalgia. *A 3/23/18 cognition score of fifteen indicated she had intact cognition. *Her initial 3/25/17 Braden Scale for Predicting Pressure Sore Risk score had been nineteen indicating she had no risk of developing pressure ulcers upon admission. Review of her initial 3/25/17 care plan revealed: *A focus area: At risk for alteration in skin integrity related to: impaired mobility fracture of right wrist had the following interventions: -Observe skin conditions with activities of daily living and report abnormalities. -Use pressure redistributing device on bed/chair. -Provide preventative skin care routinely and as needed. *The above focus area had been resolved on 9/1/17 resulting in no care plan to address skin integrity. Review of her Braden Scale for Predicting Pressure Sore Risk scores for the following revealed: *For 7/18/17 and 10/2/17 had scores of sixteen indicating she had been at risk. *For 12/5/17 had a score of twelve indicating high risk. Review of her 12/5/17 Pressure Ulcer Healing Chart form revealed: *A pressure ulcer was now present. *The length times width had been 3.1 to 4. *The exudate amount had been light. *The tissue type had been [MEDICATION NAME]. Review of her 12/5/17 care plan revealed: *She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *Interventions had included: -To assist with repositioning her in wheelchair and when in bed. -Complete a daily body audit. -To receive dietary supplements. -To encourage her to lie down during the day to reduce pressure to coccyx. --She had voiced agreement in lying down one hour per day. -Offer a whirlpool on shower days to help with circulation. -Place a pressure redistributing mattress on the bed and cushion to the wheelchair. Review of the 1/30/18 Pressure Ulcer Healing Chart form revealed the pressure ulcer had resolved. Review of the 12/5/17 care plan revealed it had been resolved on 1/30/18; there had been no care plan for skin integrity. Review of her 2/14/18 care plan revealed: *A new focus area for risk of alteration in skin integrity: related to history of pressure ulcers, impaired mobility, and incontinence had been initiated. *Interventions included: -Barrier cream to perineal area/buttocks as needed. -Encouragement to reposition as needed and use of assistive devices as needed. -Observation of skin condition with activities of daily living and report abnormalities. -Use of pressure redistributing device on bed and chair. Review of the 3/16/18 Braden Scale for Predicting Pressure Sore Risk tool revealed a score of twelve indicating high risk. Review of 3/16/18 Pressure Ulcer Healing Chart form revealed: *A pressure ulcer was now present. *The length times width had been 2.1 to 3. *The exudate amount had been none. *The tissue type had been [MEDICATION NAME]. Review of the 3/16/18 care plan revealed: *She had a stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *Interventions had included: -A daily body audit. -Dressing changes as ordered. -To encourage resident to lie down during the day. -Offer a whirlpool on shower days. -Use a pressure redistributing support surface-air pressure mattress on bed and ish-dish cushion to wheelchair. Interview on 3/27/18 at 3:52 p.m. with RN unit manager A regarding resident 8 revealed: *She had been admitted on [DATE] with no pressure ulcers. *She had not been at risk on her initial assessment but should have been due to decreased feeling/sensation in her lower body, and because she was often wet due to incontinence. *Some preventative measures had been put into place. *She had not been as talkative when she had first been admitted to the facility, so she might not have told her about the decreased sensation in her lower extremities. *She had then developed a stage two pressure ulcer. *A new care plan had been developed to reflect the stage two pressure ulcer to the right buttock related to decreased mobility and decreased sensation. *When the pressure ulcer had closed on 1/30/18 she had stopped the treatment on that day. -She felt she could have continued the treatment longer. *She did not know why there had not been preventative measures in place between 1/30/18, when the first pressure ulcer had been resolved, and 2/14/18 when the skin integrity care plan had been re-initiated. -She agreed there should have been a skin integrity care plan after the first pressure ulcer had healed. Surveyor: Observation on 3/28/17 at 1:45 p.m. of resident 8's pressure ulcer revealed: *She was lying on her left side, and had been in bed lying down to allow pressure relief to coccyx. *The dressing had been removed prior to observation. *The wound on the coccyx was almost healed. *Area was cleansed with wound cleanser. *[MEDICATION NAME] dressing was applied per physician order. Surveyor: Interview on 3/29/18 at 7:23 a.m. with the DON regarding resident 8 revealed: *All newly admitted residents had a skin assessment completed. *A skin care plan would have been developed for every new resident. *It was not as individualized towards her specifically as it could have been. *If a skin issue were to develop another care plan would have been created. *She agreed after the first pressure ulcer had healed they should have created an in-depth, individualized care plan to prevent further pressure ulcers. Observation and interview on 3/29/18 at 9:50 a.m. with resident 8 revealed: *She was lying on her left side in bed with a pillow propped under her back and hip area. *She was watching her television. *She stated she was laying down, because it was good for her bottom. -She had agreed to lie down more often. -She did not like to lay down. -Some days they asked her to lay down, and some days they did not. *She did like whirlpools. *If she sat in her wheelchair too long she could sometimes feel burning in her buttocks. Interview on 3/29/18 at 10:00 a.m. with certified nursing assistant (CNA) B revealed: *When residents had skin issues she was informed through verbal report. *Resident 8 was one resident they encouraged to lay down. -It was over a month ago that she was informed resident 8 needed to lay down every day. *They carried a sheet with residents' names and the type of assistance needed. -The sheets did not address if the residents had skin issues. Interview on 3/29/18 at 10:05 a.m. with CNA C revealed: *She did not usually work on the hall resident 8 resided on. *Verbal report had informed her resident 8 should have been encouraged to lay down. -No other instructions had been given to her regarding her skin interventions. --She was not aware she should have encouraged resident 8 to reposition herself in her wheelchair. 3. Interview on 3/29/18 at 10:10 a.m. with RN unit manager A revealed: *All different nurses were currently completing the Braden Scale for Predicting Pressure Sore Risk tool. *A new MDS coordinator had recently been hired, and she would be doing the quarterly assessments to promote consistency. *Communication to CNAs had been given during the daily verbal report. -There was also a communication book and an area to leave a communication note at the nurses station. Surveyor: Review of the providers (MONTH) 2013 Skin Practice Guide revealed: *The Braden assessment provides data on general pressure ulcer risk and assists clinicians to plan care accordingly. *The subscale scores provide information on specific deficient's such as moisture, activity, nutrition, and mobility. *Those areas could have been specifically addressed in the care plan. *Upon completing an evaluation, the interdisciplinary team develops a patient specific care plan to include prevention and management interventions with measurable goals.", "filedate": "2020-09-01"}
{"rowid": 4, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2017-05-17", "deficiency_tag": 281, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "V34811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of four sampled residents (4) who was an insulin dependent diabetic received her medications as ordered by the physician. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 4's physician's orders [REDACTED]. *[MEDICATION NAME] 3 units (u) every morning (q. a.m.). *Humalog insulin: -7 units before breakfast. -4 units before lunch. -2 units before supper. *In addition she received additional Humalog insulin on a sliding scale based on a her blood sugars: -201-250: 1 unit. -251-300: 2 units. -301-350: 3 units. -351 or greater: 4 units. *The physician was to be notified if her blood sugars were lower than 60 or higher than 450. Review of resident 4's physician's orders [REDACTED]. Review of resident 4's medical record revealed a 5/15/17 fax had been sent to her physician stating Please note that pt (patient) scheduled Humalog was missed over the weekend. Attached to that fax was a copy of her blood sugars. Interview on 5/16/17 at 10:00 a.m. with registered nurse/unit manager A regarding resident 4 revealed: *On 4/11/17 the resident's Humalog insulin for the noon meal had been changed from 3 to 4 units. *The nurse had yellowed out on the treatment record/medication record the 3 units that meant it had been discontinued. *On the next frame of the medication record she wrote the medication change increasing the noon dosage to 4 units. *She also yellowed out from 5/11/17 noon dose through 5/31/17, 5/11/17 through 5/31/17 for the supper dose, and 5/12/17 through 5/31/17 for the breakfast doses. -When a medication had been yellowed out that meant that order had been discontinued. *She never re-wrote those orders for breakfast or supper, so none of those doses were given. *The resident had missed her insulin for seven meals. *The error was found on 5/15/17 and immediately reported. *The nurse who had made the medication order change had not completed the process correctly. Review of resident 4's blood sugar records from 5/7/17 through 5/15/17 revealed her blood sugars: *Had been checked four times per day. *Her blood sugars were: -Never lower than 60, nor higher than 400. -Between 201 to 250: seven times. -251 to 300: four times. -301 to 350: four times. -350 or greater: four times. *On 5/12/17 her blood sugars ranged from 91 to 198. *On 5/13/17 her blood sugars ranged from 197 to 386. *On 5/14/17 her blood sugars ranged from 198 to 418. *On 5/15/17 her a.m. blood sugar was 145, and her noon time blood sugar was 225. Review of the provider's 8/11/06 professional standard and policy for Orders Management: Medication and Treatment Orders revealed it did not address how to change an order on the medication/treatment record. Interview on 5/17/17 at 11:00 a.m. with the director of nursing regarding resident 4 revealed: *When the above medication change occurred the nurse should not have yellowed out all of the Humalog doses without rewriting them along with the new dosage for the noon meal. -She should have put a bracket ( ) around the change and left the other medications without altering them with the yellow highlighter. *An error had been made, and the resident missed her scheduled medications.", "filedate": "2020-09-01"}
{"rowid": 5, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2019-06-26", "deficiency_tag": 561, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9U2F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and admission packet review, the provider failed to ensure one of one sampled resident's (52) choices related to her therapy schedule had been followed. Findings include: 1. Review of resident 52's medical record revealed: *She had been admitted on [DATE]. *She was alert and oriented. *Her 5/14/19 admission Minimum Data Set assessment regarding her daily preferences revealed: -It was very important for her to choose her own bedtime. --There was no question to specifically address how important her wake-up time would have been. *Her 6/26/19 care plan revealed: -Involve (resident name) in IDT (interdisciplinary team) and care planning. -Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. Observation and interview on 6/24/19 at 4:56 p.m. with resident 52 in her room revealed: *She was sitting in her bed reading a book.*She had been admitted about five weeks ago following a fall at home when she broke her hip. *She was working with therapy services and hoping to get back home soon. *Her only complaint was having to get up so early in the morning for therapy sessions. *She was not a morning person and did not feel well at that time of the day. -She further stated she used to have low blood pressure issues early in the morning. *The white dry erase board in her room indicated she would have three therapy appointments the next day at the following times: -At 6:30 a.m. with occupational therapy (OT). -At 8:30 a.m. with physical therapy (PT). -At 12:00 noon with speech therapy (ST). *She had told more than one therapy staff person that she did not like those early morning appointments, and they still scheduled her that way at times. Observation and interview on 6/25/19 at 9:05 a.m. with resident 52 in her room revealed:*She had just returned from therapy and was sitting in her wheelchair. *She had slept well the night before, and therapy had gone okay that morning. *Her preference still would have been to not do therapy so early in the morning. Observation on 6/26/19 at 8:29 a.m. of the dry erase board in resident 52's room revealed her three therapy appointments for that day were at the following times: *At 8:00 a.m. with OT. *At 12:00 noon with PT. *At 1:35 p.m. with ST. Interview on 6/26/19 at 8:45 a.m. with the social services designee regarding resident 52's concern with her therapy schedule revealed:*She had not been aware of the resident not wanting her therapy appointments so early in the morning. *If the resident had told staff she had not wanted therapy scheduled so early in the morning her preference for that should have been followed. Interview on 6/26/19 at 8:49 a.m. with the director of rehabilitation (rehab) services regarding resident 52 revealed:*He had known her for awhile, since she had been a resident in the facility for a separate stay prior to this admission. *He was aware she did not like her therapy appointments early in the morning. *Sometimes OT was scheduled at 6:30 a.m. in order to work on specific exercises such as dressing in order to get it done before breakfast started at 7:30 a.m. *He thought the resident only had one or two times when therapy had been scheduled for 6:30 a.m. since she had been admitted . Interview on 6/26/19 at 9:34 a.m. with the director of nursing regarding resident 52's therapy schedule revealed:*She expected the resident's therapy schedule to be adjusted and meet the resident's preferences. *Therapy staff could have accommodated the resident's preferences to not be scheduled early in the morning. Further interview and record review on 6/26/19 at 10:03 a.m. with the director of rehab regarding resident 52 revealed:*He brought her 5/7/19 through 6/26/19 therapy scheduled appointments list for review. *According to that list she had been scheduled for the 6:30 a.m. time on the following dates:-On 5/10/19 with PT. -On 5/24/19 with OT. -On 5/27/19 with PT. -On 6/14/19 with PT. -On 6/17/19 with PT. -On 6/25/19 with OT. *He stated she was getting three different therapies five days a week, and it could be difficult to get them all fit in during the day. *He confirmed they could have adjusted her therapy schedule to meet her preferences. *They could have worked on dressing at the time of her shower or asked her when it worked best for her to work on those dressing exercises. Interview on 6/26/19 at 10:27 a.m. with registered nurse/unit manager A regarding the above for resident 52 revealed:*She was the unit manager for the rehab unit. *Therapy appointments were scheduled by the therapy staff. *She confirmed therapy appointments should have been scheduled to accommodate the resident's preferences. Review of the provider's revised (MONTH) (YEAR) Resident Admission packet revealed:* .The rehab gym and office hours of operation are Monday through Friday 6:40 AM to 4:30 PM and Weekends by appointment only. Our therapy sessions are conducted one on one with the resident . *The inter-disciplinary team or IDT, consists of your individual case manager, therapist(s), social services, dietary, recreation and direct care supervisor. Resident and/or family participation in our IDT meetings is extremely important and highly encouraged . *The resident had a right to choices including: -(2) Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being, and -(3) Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participated in planning care and treatment or changes in care and treatment.", "filedate": "2020-09-01"}
{"rowid": 6, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2019-06-26", "deficiency_tag": 610, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9U2F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on interview, record review, and policy review, the provider failed to thoroughly investigate an incident for one of one sampled resident (47) who had a fall with a head injury. Findings include: 1. Review of resident 47's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was an eleven indicating her cognition was moderately impaired. *She required the extensive assistance of two staff members for bed mobility. *On 5/5/19 she had rolled out of bed. Review of resident 47's fall investigation from 5/5/19 revealed: *She fell out of bed. *Positioning pillows were discontinued on 12/26/19 due to limited mobility. *The staff that were present had been interviewed. -She had been provided incontinent care at 3:00 a.m. -They had been in her room at 4:00 a.m. -She was found on the floor at 4:15 a.m. --Her bed was damp, and she was wet with urine. *The investigation did not indicate the resident's position in the bed fifteen minutes prior to the fall. Interview on 6/26/19 at 8:28 a.m. with the director of nursing (DON) revealed she felt if a resident was asked immediately following an incident regardless of their BIMS score they could tell you what happened. Interview on 6/26/19 at 8:33 a.m. with registered nurse E, the director of nursing, and the administrator regarding resident 47's 5/5/19 fall revealed: *She was taken at her word for how she fell out of bed. *It was not investigated how the resident was positioned in her bed prior to the fall. -If she had been near the edge of the bed when staff were in the room fifteen minutes prior to the fall it was the expectation she would have been repositioned. -They agreed what the resident was doing prior to a fall could be added to their investigation form. *There were no other interventions evaluated prior to the implementation of the positioning pillows. *They did not know what had caused the fall. Review of the provider's (YEAR) Assessing Falls and Their Causes policy revealed: *The purposes of this procedure are to provide guidelines for evaluating/gathering data on a resident after a fall and to assist staff in identifying causes of the fall. *Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. *Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found.", "filedate": "2020-09-01"}
{"rowid": 7, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2019-06-26", "deficiency_tag": 679, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9U2F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (47) had individualized and meaningful activities offered and documented. Findings include: 1. Review of resident 47's 12/14/18 annual Minimum Data Set assessment revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was an eleven, indicating her cognition was moderately impaired. *She nor her family could be interviewed regarding her preferences. *The staff assessment of preferences was completed and revealed her preferences were: -Reading books or magazines. -Listening to music. -Being around animals. -Doing things in groups. -Participating in her favorite activities. -Spending time outdoors. Interview with resident 47 on 6/24/19 at 4:13 p.m. revealed: *She laid in her bed and watched TV during the day. *She liked to go to BINGO. Observations of resident 47 on 6/24/19 from 4:10 p.m through 7:15 p.m., on 6/25/19 from 7:30 a.m. through 6:45 p.m., and on 6/26/19 from 7:30 a.m. through 3:00 p.m. revealed: *She was in her room in her bed. *She was in her room in her wheelchair. -Her TV was on at times. *She went to the dining room for meals. Review of resident 47's 6/25/19 care plan revealed: *She was receptive to: -Music. -Special events. -BINGO. -Manicures. -Visiting with staff. -Volunteers. -Pet visits. -Watching TV, specifically channel 25. Review of resident 47's activity logs revealed: *In (MONTH) 2019 she was not offered activities eleven of thirty days. -On four other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she was not offered activities on eight of thirty-one days. -On five other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she had not been offered activities twelve out of twenty-five days. -On six other days she had only been offered leisure cart and refused it. Interview on 6/26/19 at 9:14 a.m. with the activity director revealed: *The leisure cart served a dual purpose that was to promote hydration and one-to-one visits with residents. *There was no set amount of time she spent with residents. *If residents needed assistance with hydration she could spend up to ten minutes in the room. *There was no assessment for determining resident needs for activities. *There was no criteria for one-to-one visits. *Resident 47 went to music activities and stayed in her room. *She indicated resident 47 was visited weekly by a dog that came to the facility. -Documentation showed she was visited by the dog one of four weeks in April, three of four weeks in May, and zero of four weeks in June. -She agreed it should have been documented when activities were refused. Review of the provider's undated Activity Programs policy revealed: Activity programs designed to meet the needs of each resident are available on a daily basis. Review of the provider's undated Individual Activities and Room Visits Program policy revealed: *Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. *Typically a room visit is ten to fifteen minutes in length. Review of the provider's (YEAR) Charting and Documentation policy revealed: All services provided to the resident, progress towards care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.", "filedate": "2020-09-01"}
{"rowid": 8, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2019-06-26", "deficiency_tag": 744, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9U2F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (69) who had dementia and behaviors had received appropriate interventions and documentation to support her psychosocial well-being. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Review of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's 6/26/19 care plan revealed: *Seven of eleven interventions for anxiety were implemented on 2/26/19. *Interventions included: -Administer medication per physician orders [REDACTED]. Try non-pharmacological interventions on her; offer the bathroom, offer something to eat and drink, monitor her health status/pain, try and redirect her to an activity in her room or in a group setting. She does like to watch TV sometimes. -Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. -Identify and decrease environmental stressors. --Initiated 6/13/18. -Offer 1:1 conversation. -Offer snacks of her liking. -Offer talking books/headphones/MP3 player of her favorite music. -Offer to turn her air conditioner on when she states she is too warm or states she can't breath. -Psych consult and treatment. -Recruit and encourage attendance at activities. -Utilize essential oil diffuser in her room with oils when she requests. -Ensure that her hand held fan is within reach. --Initiated 2/26/19. Interview on 6/26/19 at 2:40 p.m. with certified nursing assistants C and D regarding resident 69 revealed: *She was used to having someone in her room with her. *She got lonely in her room and called out. *She typically did not know what she needed but wanted people to sit with her in her room. *She liked when staff sat with her. *She had two or three people who could come and sit with her during the day. *They would explain to her she needed to use her call light and not yell out. *Sometimes they would turn on her music or TV. Resident 69 had not received appropriate dementia care and services to meet her behavioral and psychosocial needs. Refer to F758 finding 1.", "filedate": "2020-09-01"}
{"rowid": 9, "facility_name": "PRAIRIE HEIGHTS HEALTHCARE", "facility_id": 435004, "address": "400 8TH AVENUE NW", "city": "ABERDEEN", "state": "SD", "zip": 57401, "inspection_date": "2019-06-26", "deficiency_tag": 758, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9U2F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (69) had appropriate documentation to support the rationale for adding and increasing [MEDICAL CONDITION] medications. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Observation and interview on 6/24/19 at 4:40 p.m. with resident 69 revealed: *She liked the facility. *The staff were nice to her. *She did not display any signs or symptoms of anxiety during the interview. Random observations of resident 69 on 6/25/19 from 7:30 a.m. through 6:45 p.m. and on 6/26/19 from 7:30 a.m. through 4:00 p.m. revealed: *She was sitting in her room in her wheelchair. *Visitors were playing cards with her at times. *Her essential oil diffuser was on at times. *No yelling out was noted. Review of all of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's medication administration records revealed: *On 12/26/19 [MEDICATION NAME] 2.5 milligrams (mg) was added at bed time for anxiety. *On 6/13/19 the [MEDICATION NAME] was increased to 2.5 mg twice daily. *She was also receiving scheduled and as needed [MEDICATION NAME]. Review of resident 69's 6/26/19 care plan revealed: *Seven of eleven interventions for anxiety were implemented on 2/26/19. -Those were two months after the [MEDICATION NAME] had been started. *Interventions included: -Administer medication per physician orders [REDACTED]. Try non-pharmacological interventions on her; offer the bathroom, offer something to eat and drink, monitor her health status/pain, try and redirect her to an activity in her room or in a group setting. She does like to watch TV sometimes. -Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. -Identify and decrease environmental stressors. --Initiated 6/13/18. -Offer 1:1 conversation. -Offer snacks of her liking. -Offer talking books/headphones/MP3 player of her favorite music. -Offer to turn her air conditioner on when she states she is too warm or states she can't breath. -Psych consult and treatment. -Recruit and encourage attendance at activities. -Utilize essential oil diffuser in her room with oils when she requests. -Ensure that her hand held fan is within reach. --Initiated 2/26/19. Interview on 6/26/19 at 10:33 a.m. with registered nurse [NAME] and the administrator regarding resident 69 revealed: *She had anxiety. *She yelled out when people were not with her. *She was typically okay when people were with her. *Some of the interventions for her anxiety were implemented after she had started the [MEDICATION NAME]. *She had an order for [REDACTED]. *Her family knew she did better when people were with her, and they had hired two individuals to be with her in the afternoons. Interview on 6/26/19 at 2:40 p.m. with certified nursing assistants C and D regarding resident 69 revealed: *She was used to having someone in her room with her. *She got lonely in her room and called out. *She typically did not know what she needed but wanted people to sit with her in her room. *She liked when staff sat with her. *She had two or three people who could come and sit with her during the day. *They would explain to her she needed to use her call light and not yell out. *Sometimes they would turn on her music or TV. Review of the provider's (YEAR) Antipsychotic Medication Use policy revealed: Antipsychotic medications may be considered for residents with dementia but only after medial, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.", "filedate": "2020-09-01"}
{"rowid": 10, "facility_name": "AVANTARA MILBANK", "facility_id": 435009, "address": "1103 SOUTH SECOND STREET", "city": "MILBANK", "state": "SD", "zip": 57252, "inspection_date": "2018-10-03", "deficiency_tag": 584, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LZ7K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to ensure the heater units that circulated hot water in five of eight resident rooms (401, 403, 405, 406, and 408) on one of five resident halls (400) had missing front heat shields. Findings include: 1. Observation during the survey on 10/1/18 from 4: 00 p.m. through 4:30 p.m., 10/2/18 from 1:00 p.m. through 3:00 p.m., and 10/3/18 at 4:00 p.m. revealed: *Resident rooms 401, 403, 405, 406, and 408 heater units had damage to them including: -The front heat shields had exposed sharp heating fins. -The front heat shields were not attached and had exposed sharp connectors. -Half of the front heat shield was missing from room [ROOM NUMBER]'s heater and his comforter had fallen onto the heating fins. Interview on 10/3/18 at 6:00 p.m. with the administrator revealed she was not aware of the heater units disrepair. She agreed those units could have caused injury to residents. She was not aware of any policy or preventative maintenance schedule that was completed for each room. She had just initiated a system for reporting items to be fixed to maintenance.", "filedate": "2020-09-01"}
{"rowid": 11, "facility_name": "AVANTARA MILBANK", "facility_id": 435009, "address": "1103 SOUTH SECOND STREET", "city": "MILBANK", "state": "SD", "zip": 57252, "inspection_date": "2018-10-03", "deficiency_tag": 609, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LZ7K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, record review, and policy review, the provider failed to ensure investigations had been completed for 3 of 3 incidents for 1 of 14 sampled residents (37) for potential verbal, mental, and physical abuse. Findings include: 1a. Observation and interview on 10/2/18 at 3:00 p.m. with resident 37 shared her concerns including the following: *She stated the staff reminds me of one big [NAME]s and she does not need that in her life. *She did not want those people in her life, and when she asked to have other staff assist her she was told she had to accept whoever was assigned. *She stated staff did not answer her call light for hours and sometimes not at all. *She was seated on her bed with a tray table in front of her. *Her wheelchair was located across the room and pushed under the sink. *She was unable to use her right hand due to a previous stroke. *At 3:16 p.m. she pressed her call light. *At 3:22 p.m. this surveyor went into the hall to ensure the light had been activated and the light was on. *At 3:35 p.m. an unidentified male staff person came into the room and told her he would get someone else to assist her. *At 3:38 p.m. the director of nursing (DON) entered the room, stated she did not usually help her but would do her best, and used the standing lift to assist her to the commode. Review of resident 37's medical record revealed: b. On 06/23/18 at 1:33 p.m. a progress note by the DON revealed the resident had told staff she had blisters on her left hand. The DON had documented: -Firm blisters on the knuckles of the left thumb, index, 3rd and 4th fingers. Thumb being the largest. Skin on the back of hands is very ruddy and red. *On 06/25/18 an incident follow-up notation completed by the DON revealed: -Discussed by (interdisciplinary team), resident is known to run hot water for long periods of time, up to 2-4 hours to wash her hair and this is what she has been doing. No amount of verbal counseling will change this as it is part of her ([MEDICAL CONDITION]) ([NAME]D) behavior, she has a need to rinse her hair multiple times. Maintenance will. Handwritten by the DON verify the water temp is in safe range in the room. *On 06/25/18 at 1:45 p.m. she was seen by the Certified Nurse Practitioner (CNP): I am making 60 day rounds for (resident 37's physician). (Resident 37) has multiple health problems. She does have a history of [NAME]D. She was washing her hair and this is quite an extensive chore for her and it usually takes quite a long time. She burned both of her hands from washing her hair. She has been applying vitamin D. And she has been drinking more[NAME]water to help her hands. Bilateral hands are [DIAGNOSES REDACTED]tous (red) she has blisters on 1,2, and 3 (fingers) of both hands. No drainage present. -Handwritten note by the DON only (left) hand had blisters-doesn't use (right) hand. R/[MEDICAL CONDITION](related to stroke). *A 06/26/18 at 11:04 p.m. weekly skin check revealed: Only new skin concern is that (resident) has some [MEDICAL CONDITION] bilateral fingers that are being (treated) with Vit E.[MEDICAL CONDITION] drying up, has been blistered. Appear to be healing nicely. *06/26/18 an incident follow-up notation completed by the DON revealed: -Maintenance checked the water (temperature) and it is 117.7 (degrees Fahrenheit), this is below the recommended 125 (degrees Fahrenheit). Resident also thinks that someone flushed a toilet making the water hotter, it is explained to her that in a household that can happen but that the plumbing in the facility does not work that way. *A weekly skin check on 07/3/18 at 4:55 a.m. revealed she was complaining of pain related to [MEDICAL CONDITION] left thumb and first finger. c. On 08/24/18 at 12:00 midnight a progress note by licensed practical nurse (LPN) A revealed she had overheard an unidentified assistive personal (UAP) was in the room with resident 37, the UAP had bumped resident 37's foot two times during a transfer. Resident 37 got upset and was yelling at the UAP. The UAP put her on the commode and left the room. -LPN A entered the room to assess the foot and resident 37 was still upset. -LPN A noted This nurse told resident when she stopped screaming and calling staff names, and calmed down that some(one) would come and assister her off commode. This (LPN A) then left room. Resident did calm down, was assisted off commode and is now on her bed eating popcorn. Interview on 10/3/18 at 4:45 p.m. with the social services designee revealed he: *Only took care of grievances. *Did not take care of any complaints or investigations. *Thought the administrator did those investigations. Interview on 10/3/18 at 6:00 p.m. with the DON revealed she: *Confirmed the above medical record review documentation. *Stated she had determined [MEDICAL CONDITION] been caused by resident 37. *Stated the blisters had healed in one day. *Was not aware of the incident on 08/24/18 and stated the resident had always sat on the commode for a long length of time. *The nurses had not been trained to start an investigation. They were to have called the DON or administrator. Interview on 10/3/18 at 6:30 p.m. with the administrator revealed she: *Was not aware of the above incidents. *Signed off on the DON's investigations. *Was aware of the requirement of investigations and reportable incidents. Review of the provider's (MONTH) (YEAR) Abuse, Neglect, and Exploitation policy revealed: *The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: -Administrator -Other Officials in accordance with State Law -State Survey and Certification agency through established procedures. *Investigation of Alleged Abuse, Neglect, and Exploitation. When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: -Interview the involved resident -Interview all witnesses separately. Include staff members in the area. -Document the entire investigation chronologically.", "filedate": "2020-09-01"}
{"rowid": 12, "facility_name": "AVANTARA MILBANK", "facility_id": 435009, "address": "1103 SOUTH SECOND STREET", "city": "MILBANK", "state": "SD", "zip": 57252, "inspection_date": "2019-11-06", "deficiency_tag": 584, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "O5MT11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure a sanitary and homelike environment was maintained for: *One of one randomly observed laundry service area was clean and in good condition. *The heating system in one of one laundry service area was working properly to ensure the temperature in the room was maintained at a comfortable working level. *The ceiling tile on four of four observed wings (100, 300, 400, and 500) was clean and in good repair. *Multiple metal brackets and hardware holding the ceiling tile in place for four of four observed wings (100, 300, 400, and 500) had cleanable surfaces. Findings include: 1a. Observation and interview on 11/5/19 at 9:30 a.m. with laundry assistant A of the laundry service area revealed: *The flooring in the entire area was tiled. -Multiple tiles throughout the area were chipped or had broken pieces off of them. Those missing and chipped pieces of tile: --Were rough and jagged around the edges of it. --Created and exposed a concrete surface that was uncleanable. *The entire wall located by the two clothes dryers and resident clean clothes storage area was warped, chipped, and missing large areas of paint. -Those areas covered greater than 50% (percent) of the wall. -Those areas had exposed the wall board and gypsum underneath of it to create an uncleanable surface. *There were four wooden doors in that area. -The protective covering on those doors was gouged, chipped, or missing in several areas. --Those areas exposed the raw wood underneath of it and created an uncleanable surface. *There were two clothes dryers in the clean clothes area. The protective covering on the outside surfaces of one of those dryers was missing and was rusted underneath of it. -Those rusted areas created an uncleanable surface. *There were two small metal clothes carts in the clothes drying area. She used the carts to transport the clean linens from the washer to the dryers. -Those carts: --Were on wheels and had the capability of being rolled to other areas of the room and facility. --Had large open holes to all the surfaces on it, so the laundry was exposed to the environmental elements during transportation of it. --A protective material covering the metal on the carts. The material was chipped and missing in multiple areas. Those chipped and missing pieces of covering created uncleanable surfaces for the clean laundry to be transported in and on. *The grates on two of four ceiling vents: -Were dirty with gray colored lint. -Were metal and had several areas that were rusted on them. --Those rusted areas created uncleanable surfaces. *The ceiling had been covered with wall board and was painted. -The paint was warped, cracked, and pulling away from the wall board in several places in all areas of that room. Continued observation and interview on 11/5/19 at 9:35 a.m. with laundry assistant A of the laundry service area revealed: *The room was quite cold and caused the surveyor to shiver. -The surveyor was dressed in a sweater, long pants, and boots. *The laundry assistant stated: -There is no heat in this room, I know it's freezing in here. -I've worked here 5 1/2 years and I don't think it has ever worked. -They know about it, I just put up with it, and keep moving I have no choice. Interview on 11/5/19 at 1:20 p.m. with the laundry service supervisor B revealed he: *Had been aware of all the concerns identified above. *Stated: -Management is aware of the problems in that room. -It's been like that for a while, we've tried to paint it and keep it as clean as we can. *Confirmed the heat did not work in the laundry service area and made for an uncomfortable environment for him and his staff to work in. *Stated: During the winter I wear my heavy coat in there because it's so cold. b. Random observations on 11/4/19 from 2:10 p.m. through 5:30 p.m. of the ceiling tile and the metal brackets on the 100, 300, 400, and 500 wings revealed: *That tile was in the shape of squares and was held in place by metal brackets. *That tile was: -Torn in multiple areas and exposed the insulation inside of it. -Warped and did not fit properly in the metal brackets in multiple areas. *The metal brackets holding the tile in place were rusted in several areas. -Those rusted surfaces had created uncleanable surfaces. c. Interview on 11/5/19 at 1:30 p.m. with the administrator revealed: *She confirmed the observations and interviews above. *There had been budget restraints in the past, and she was hopeful that would change with the new ownership and help with repairs that were needed. *She stated: -It needs a new roof because it's leaking in several areas all over the building. -They said they are doing things in phases, and the repair for that is phase two. *There were no certain dates and times specified for when she could have expected those repairs to occur or be initiated. Review of the provider's 5/1/11 Maintenance Services policy revealed: *To assure that the facility's buildings, grounds, and equipment are maintained in a safe and operable manner at all times. *All facilities managed by (provider name) shall implement a policy to assure that the facility is periodically maintained to assure its effective and efficient operation. *The maintenance department will operate the facility in compliance with current federal, state, and local laws, regulations and guidelines that may include, maintaining: -The building in good repair and free from hazards. -The heating, ventilation, and air conditioning systems in proper working order. *The maintenance department will work with facility administration and corporate Facility Services staff to establish priorities for repair and replacement of critical building components and infrastructure. *The Administrator is responsible for the overall supervision of the Environmental Services Department.", "filedate": "2020-09-01"}
{"rowid": 13, "facility_name": "AVANTARA MILBANK", "facility_id": 435009, "address": "1103 SOUTH SECOND STREET", "city": "MILBANK", "state": "SD", "zip": 57252, "inspection_date": "2019-11-06", "deficiency_tag": 684, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "O5MT11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to follow professional standards to ensure physician notification, ongoing skin assessments, and treatments had occurred for one of one sampled resident (45) who had a change in the condition of her skin. Findings include: 1. Observation on 11/4/19 at 2:11 p.m. of resident 45 revealed: *The resident's door to her room had been partially shut. *Upon knocking on the door there was no answer. *The room was darkened with her window curtains partially opened and the television on. *She: -Was laying in her bed resting on her left side and facing the wall. -Had an air mattress on her bed to ensure pressure relief occurred -Was dressed in a bedtime hospital type gown. -She opened her eyes and made eye contact when spoken to but made no attempt to respond. -Was not observed making any spontaneous body movements. Interview on 11/4/19 at 2:29 p.m. with licensed practical nurse (LPN) G regarding resident 45 revealed: *The resident was recently placed on bedrest. *She stated: -It hurts her too much to transfer her with the lift. -She's comfort care. Observation on 11/4/19 at 4:30 p.m. of resident 45 revealed the same as observed above at 2:11 p.m. Observation and interview on 11/4/19 at 4:34 p.m. with certified nursing assistants (CNA) C and D with resident 45 revealed: *They had prepared to assist the resident with repositioning and personal care. *The resident had: -Been incontinent of both urine and bowel movement (BM). -Been in the same position as observed above at 2:11 p.m. -Required the CNAs to assist her with positioning, incontinence care, and dressing. *When she had been turned onto her right side there was a large circular reddened area on her left buttock. -That area was approximately 12 centimeters (cm) by (x) 7 cm in size and was the color of a red apple. -The entire edge of the wound was a deeper red and approximately 0.25 cm in width. -The entire surface of the wound had been smooth, intact, gave no appearance of being dry, and peeling was noted. -Was located on an area of the skin where a pressure injury could have occurred. *CNA C stated: -She always gets red areas like that. -We use a barrier cream or zinc on them. Interview on 11/5/19 at 8:10 a.m. with the director of nursing (DON) regarding resident 45 revealed: *She confirmed the interview with LPN [NAME] *She stated: -She's been in bed ever since her fall. -She was sitting on the edge of the bed while the CNA was dressing her and started to slide to the floor. The CNA lowered her to the floor. -The x-ray didn't show a fracture, but sometimes they don't show-up until later or when another x-ray is done. -Her right leg is swollen though. -Her family just recently decided not to have another x-ray done and put her on comfort care. -She's not a surgical candidate. Random observations on 11/5/19 from 7:35 a.m. through 10:28 a.m. of resident 45 revealed: *She: -Had been laying in her bed sleeping. -Was laying on her back with her heels directly on the air mattress. There was no other pressure relieving measure in place for her heels. *The head of her bed was elevated, and she had scooted down in the bed. -That position had caused the bottom of her feet to be flat up against the footboard of the bed. *That morning the surveyor had requested multiple times from the staff to observe them while assisting the resident with any and all personal care. -The staff had not approached the surveyor during those three hours to observe them while assisting the resident. Observation and interview on 11/5/19 at 12:41 p.m. of CNA D with resident 45 revealed: *The resident had: -Been assisted with her lunch and was positioned on her left side. -No pressure relieving devices between her knees or underneath of her legs/feet. *She assisted the resident with incontinence care and repositioning to her right side. *The resident continued to have the large reddened area on her left buttock. *CNA D stated: -She gets that every now and then; we just put a barrier cream on it or zinc. -She had it last week when I worked. -No no one ever said anything about it in report. -I don't know, I guess maybe they should have said something. -I don't know for sure if the nurse knows about it or not. -We are supposed to position her every two hours. -I move her more than that though, cause I put her on her back to eat then turn her afterwards. -So no, she was moved, I know she was. Review of resident 45's paper and electronic medical record revealed: *She was admitted on [DATE]. *[DIAGNOSES REDACTED]. *Her Braden Scale for Predicting Pressure ulcers score as of 9/30/19 was a twelve indicating she was at moderate risk for skin breakdown. *She had: -Periods of confusion and problems with both short and long term memory recall. -Required the CNAs to assist her with positioning, incontinence care, transfers, and dressing. *On 10/4/19 she: -Had a fall with an injury while being assisted by the CNA with dressing. -Had been sitting on the side of her bed while the CNA was assisting her. -Was leaning forward, started to slide down off of the bed, and the CNA lowered her to the floor. -Had been sent to the emergency room to rule out a fracture of her right leg/hip. *The x-ray did not support an injury to that leg, but it had been quite swollen and painful. -The physician had ordered medication for pain control. *She had a history of [REDACTED]. -Those areas had been to her elbows, under her abdominal folds, and breasts. *Staff were to have applied various types of creams and ointments to those areas until healed. *There was no documentation to support: -She had a skin concern to her left buttock that required the staff to monitor and treat until healed. -The physician was notified of that area on her left buttock to ensure the appropriate treatment was in place to promote proper healing of it. Review of resident 45's 8/1/19 through 11/4/19 treatment assessment record (TAR) revealed: *She: -Was to have her skin assessed by the professional staff every week on Thursday evenings. -Had skin concerns on her elbows, abdominal folds, and under her breasts that required various types of treatment for [REDACTED]. *There was no documentation to support: -The staff were to monitor an area of concern on her left buttock to ensure healing had occurred. -An order from her physician for a treatment was received and put in place to promote healing for a skin concern on her left buttock. Review of resident 45's 8/1/19 through 10/31/19 weekly skin evaluations revealed: *On 10/10/19 the nurse had documented: -Site: Left buttock. -Description: Approximately 6 (inches) circular reddened area that is blanchable, zinc applied with each brief change. Review of resident 45's 8/12/19 through 11/3/19 nursing progress notes revealed no documentation to support: *The professional staff had assessed and treated a skin concern on her left buttock. *The physician was notified to ensure they had provided the proper treatment to promote healing of that skin concern. Observation and interview on 11/5/19 at 3:32 p.m. of registered nurses (RN) F and H and CNA I with resident 45 revealed: *CNA I stated: She's had that spot in the past before. It's part of her psoriasis issue. *RNs F and H: -Had not been aware of the skin concern located on the resident's left buttock. -Assessed the area and a majority of the area was blanchable. *RN H confirmed the resident had a history of [REDACTED]. *RN H agreed the nurse who had initially assessed that area should have: -Notified the physician to ensure the appropriate treatment and monitoring was put in place to promote proper healing of it. -Notified the direct care givers and other professional staff of that area to further support the proper monitoring and treatment of [REDACTED]. -Identified the area on her left buttock on the TAR to ensure the staff had monitored it for healing. *They agreed she: -Was at high risk for skin breakdown and required staff support for proper positioning. -Should have been repositioned at a minimum of every two hours. *RN H was not sure she had required extra pressure relieving measures for her feet and heels with the use of an air mattress. Interview on 11/5/19 at 4:56 p.m. with the DON regarding resident 45 revealed she: *Confirmed the resident was: -At risk for skin breakdown and should have been repositioned at a minimum of every two hours. -Dependent upon the staff to ensure all of her activities of daily living (ADL) had occurred. Those ADLs had included repositioning, incontinence, and skin care. *Agreed the air mattress would not have guaranteed no skin breakdown would not have occurred without the support of positioning and pressure relieving devices. *Would have expected there to have been pressure relieving devices between her knees and underneath her heels. *Confirmed the resident had a history of [REDACTED]. *Was not aware of the skin concern on the resident's left buttock. *Was undecided if the nurse who had initially assessed that area should have: -Contacted the physician to ensure the resident received the appropriate treatment to promote the healing of it. -Ensured the TAR was updated for the other staff to monitor that area to ensure healing of it had occurred. -Ensured the direct care givers and other nursing staff had been aware of the area on her left buttock. Review of the provider's 5/1/15 Weekly Skin Review UDA (user defined assessments) policy revealed: *A weekly skin review UDA (user defined assessments) will be completed weekly on all residents and patients to check for any new skin issues not previously identified. *MD/NP (medical doctor and/or nurse practitioner) are to be notified of any skin alterations, as well as the resident/patient, and his/her responsible party. Review of the provider's 11/12/14 Notification of Change in Resident Health Status policy revealed: *Guideline Statement: To ensure that proper notifications are made when a resident has a change in health status. *Such as: A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.)", "filedate": "2020-09-01"}
{"rowid": 14, "facility_name": "AVANTARA MILBANK", "facility_id": 435009, "address": "1103 SOUTH SECOND STREET", "city": "MILBANK", "state": "SD", "zip": 57252, "inspection_date": "2019-11-06", "deficiency_tag": 880, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "O5MT11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions had been maintained during personal care for three of five sampled residents (15, 20, and 45) by three of three observed certified nursing assistants (CNA) C, D, and E. Findings include: 1a. Observation on 11/4/19 at 3:36 p.m. with CNAs C and D with resident 20 revealed: *The resident had been sitting on the edge of her bed sorting her mail. *She had been incontinent of bowel movement (BM). -Her BM was so large it had run out of the incontinent brief and down her right thigh. *She had required the use of a mechanical stand-aide for transfers. *The CNAs prepared to assist the resident with personal care and a transfer from her bed onto a bedside commode. *Without washing or sanitizing their hands upon entering the room they put on a clean pair of gloves. *With those gloves on CNA D: -Moved the stand-aide closer to the resident. -Removed the blanket off the resident's lap. -Touched the handle on the water faucet and turned the water on. -Got a package full of dry wipes, opened that package, and wet the dry wipes. -Touched the handle on the water faucet and turned the water off. -Took the wet wipes and started to clean the BM off of her thigh. -Removed her gloves and without sanitizing or washing her hands put on another pair of gloves. *With those gloves on CNA D: -Assisted CNA C with using the stand-aide to stand the resident up. -Removed the resident's incontinent brief and took several of the wet wipes and cleaned BM off her bottom. *With those soiled gloves on she took more wet wipes and cleaned the resident's front perineal area. --The CNA cleaned her front area by wiping from the back towards the front of her perineal area. --There had been BM on several of those wet wipes. *Both of the CNAs removed their gloves and assisted the resident to sit down on the bedside commode. *They washed their hands prior to leaving the room to offer the resident privacy and wait for the bath-aide to assist them further. -That had been the only time they were observed washing or sanitizing their hands during the above observation. *CNA D had not attempted to: -Use a barrier between her gloves and the water faucet handle when turning the water faucet on and off. -Open the package of dry wipes prior to putting on gloves that were used to clean the resident with. -Clean the resident's front perineal area prior to cleaning her bottom of BM. -Change her gloves and wash or sanitize her hands after cleaning the resident's bottom that had BM on it prior to cleaning her front perineal area. -Ensure she cleaned the resident's perineal area from front to back. b. Observation on 11/4/19 at 4:34 p.m. of CNAs C and D with resident 45 revealed: *The resident had been laying on her bed and was ready to be repositioned. *They prepared to assist her with personal care and to position her on her right side. *Without washing or sanitizing their hands upon entering the room they put on a clean pair of gloves. *With those gloves on they: -Raised the resident's bed up to a workable level by using the hand remote. -Pulled the resident's blanket off her and removed her incontinent brief. *Both CNAs C and D had touched the water faucet handle and turned the water on and off to wet some dry wipes. *CNA C cleaned the resident's front perineal area first, and then CNA D cleaned the resident's bottom. -She had been incontinent of BM. *Without removing their soiled gloves they: -Put a clean incontinent brief on the resident. -Positioned her in bed on her right side. -Placed a pillow behind her back and covered her with the blanket. *Both of the CNAs removed their gloves and washed their hands prior to leaving the resident's room. -That had been the only time they were observed washing or sanitizing their hands during the above observation. *They had not: -Changed their gloves and washed and/or sanitized their hands after positioning the bed, removing the blanket, and taking off her incontinent brief. -Used a barrier between their gloves and the water faucet handle when turning the water faucet on and off. -Changed their gloves and washed and/or sanitized their hands after providing personal care for the resident. c. Observation on 11/5/19 at 10:36 a.m. with CNA [NAME] with resident 15 revealed: *The resident had been laying on her bed and was ready to be assisted with a bed bath. *The CNA prepared to assist the resident with that bed bath. *After gathering all her supplies CNA [NAME] washed her hands and put on a clean pair of gloves. *With those clean gloves on she washed her hair, face, and upper torso. *CNA E: -Changed the water in the basin and removed her gloves. -Washed her hands and put on a clean pair of gloves. *With those clean gloves on CNA E: -Took a washcloth, wet it with the water in the basin, and applied some soap to it. -Took the washcloth and cleaned both of her legs and feet with it. *CNA [NAME] used those soiled gloves and that soiled washcloth to: -Rinse the washcloth in the same water used to wash her legs. -Apply soap to that washcloth and clean the resident's front perineal area with it. *CNA [NAME] removed her gloves and washed her hands. d. Interview on 11/5/19 at 1:05 p.m. with CNA D regarding the above observations of personal care for residents 20 and 45 revealed: *That had been her usual process for providing personal care for the residents. *She had not recognized the process as unsanitary until after the observations were reviewed with her. *She agreed: -The personal care provided above had not been provided in a sanitary manner and placed the residents at risk for acquiring an infection. -They should have removed their gloves and washed or sanitized their hands after they were soiled with BM. -They should have washed and/or sanitized their hands prior to entering the resident's room. *She could not remember the last time she had been observed by the professional staff while providing personal and/or perineal for the residents. Interview on 11/5/19 at 3:20 p.m. with registered nurse F and the director of nursing regarding the above observations revealed: *They agreed the personal care above had not been completed in a sanitary manner. *The staff were required to provide personal care for the resident's bottom area prior to cleaning their front perineal area. *The CNAs should have: -Washed and/or sanitized their hands upon entering the resident's room to assist them with care. -Removed their gloves and/or sanitized their hands anytime they had been soiled. *They agreed the processes above had created the potential for the residents to have acquired an infection. Review of the provider's (MONTH) 2014 Handwashing/Hand Hygiene policy revealed: *This facility considers hand hygiene the primary means to prevent the spread of infections. *All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. *The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.", "filedate": "2020-09-01"}
{"rowid": 15, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2018-02-07", "deficiency_tag": 609, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "TWBV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure: *Four of four unwitnessed falls with injury had been reported to the South Dakota Department of Health (SD DOH) in a timely manner for two of two sampled residents (17 and 62). *Thorough investigations had been completed for three of three falls for one of one sampled resident (62) who had cognitive impairment. Findings include: 1a. Review of resident 62's medical record revealed: *She had been admitted on [DATE]. *She had fallen on 11/21/17, 12/9/17, and 12/17/17. Review of resident 62's 1/2/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was six indicating her cognition was severely impaired. *She had two or more falls with injury during that assessment period. b. Review of resident 62's 11/21/17 internal fall report revealed: *She had fallen at 5:05 p.m. in her room. *Staff heard her calling for help from her room. *Upon entry she was found lying on her back with her head towards the doorway. *The walker had been laying across her abdomen. *She stated she was throwing a piece of trash away. *She stated she hit head. -Staff had noted a reddened area on the back of her head. *Staff initiated neurological checks. *They had not reported the fall to the SD DOH. *The following had not been included in the investigation: -Her level of orientation. -What level of assistance she required. -When staff had assisted her last. *There had been no documentation of if the care plan had been followed. *There had been no documentation of staff interviews. c. Review of resident 62's 12/9/17 internal fall report revealed: *She had fallen at 11:00 a.m. in her room. *Staff heard her calling for help. *They found her lying on the floor in front of her recliner. *She stated she stood up to look into her dresser, turned, and fell down. *She had complained of right shoulder pain. *Staff initiated neurological checks. *They had not reported the fall to the SD DOH. *The following had not been included in the investigation: -What level of assistance she required. -When staff had assisted her last. -It had been marked she was on a toileting program, but it had not included when she had last used the bathroom. *There had been no documentation of if the care plan had been followed. *There had been no documentation of staff interviews. d. Review of resident 62's 12/17/17 internal fall report revealed: *She had fallen at 1:10 a.m. in her room. *Staff found her on the floor in front of her recliner. *She was unsure how she had gotten on the floor. *Staff initiated neurological checks. *She slept in her recliner, and the foot of the recliner had still been raised. *She complained of right hip pain and was transferred to the emergency room (ER). *They had not reported the fall to the SD DOH. *The following had not been included in the investigation: -What level of assistance she required. *There had been no documentation if the care plan had been followed. *There had been no documentation of staff interviews. Surveyor: 2. Review of the resident 17 complete medical record revealed: *She had been found on the floor in her room on 12/31/17 at 7:50 p.m. *She was able to move all extremities without pain. *Staff had put an ice pack on her forehead. -No time was documented. *She was sent to the emergency room per ambulance on 1/1/18 at 5:00 a.m. -After her eye had started to blacken. -When her neuological checks had changed. *That incident had not been reported to the SD DOH. Surveyor: 3. Interview on 2/7/18 at 11:30 a.m. with resident care coordinator A revealed: *They would not have reported the above falls to the SD DOH unless there was a fracture or bleeding. *If someone had been sent to the ER and a fracture was found they would then report to the SD DOH. *When asked about meeting the two-hour time frame for reporting major injuries she was unsure how they would meet the two-hour requirement with their current process. *They had not reported resident 62's above mentioned falls to the SD DOH. Interview on 2/7/18 at 3:42 p.m. with the director of nursing and the administrator regarding the above falls for resident 62 revealed: *They had not reported any of the above falls due to there being no fracture. *They understood major injury to be a fracture and had not thought they should have reported the above falls. *They had no other documentation regarding the above investigations. Review of the provider's 10/11/12 Abuse Investigations policy revealed: *All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. *The investigation process should have included at a minimum the following: -Review the completed documentation forms. -Review the resident's medical record to determine events leading up to the incident. -Interview the person(s) reporting the incident. -Interview any witnesses to the incident. -Interview the resident (as medically appropriate). -Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition. -Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. -Interview the resident's roommate, family members, and visitors. -Interview other residents to whom the accused employee provides care and services. -Review all events leading up to the alleged incident.", "filedate": "2020-09-01"}
{"rowid": 16, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2018-02-07", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TWBV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure care plans had been revised and updated to reflect the individual care needs for two of seven sampled residents (13 and 62). Findings include: 1. Review of resident 13's 11/21/17 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status score was three indicating her cognition was severely impaired. *She had not demonstrated any physical behaviors. *Verbal behaviors directed towards others had occurred one-to-three days. *Other behavioral symptoms not directed toward others had occurred one-to-three days. *No rejection of care had occurred. *She had wandered one-to-three days. *She required extensive assistance of two staff members to transfer. *She required supervision with assist of one staff member for eating. *She required extensive assistance of one staff member for bathing. *Her [DIAGNOSES REDACTED].>-Hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Other fracture. -[MEDICAL CONDITIONS]. -Non-Alzheimers dementia. *She had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Observation on 2/5/18 from 5:35 p.m. through 6:00 p.m. of resident 13 revealed: *She had been sitting in the dining room waiting for supper at 5:35 p.m. *She was getting agitated and speaking loudly to the two male residents at the table. *At 6:03 p.m. she hit one of the male residents on his hand while yelling at him. *She then picked up her silverware and pulled her arm back as if to throw them at him. *She swore at him several times calling him a name. *Earlier she had been yelling across at the other male resident about his glasses. *At 6:06 p.m. she again started to call the male resident names. *There had been no staff that intervened. Observation on 2/5/18 at 6:13 p.m. of resident 13 revealed: *She was served her food. *She stated she did not want it. *She raised her voice to staff and told them to take it away which they did. *The staff member asked if she wanted ice cream, and she took that from her. -She ate it with a knife. Observation on 2/5/18 at 6:15 p.m. of resident 13 revealed staff brought her another plate and left it in front of her. She again stated she did not want it and did not eat it. Interview on 2/6/18 at 9:14 a.m. with certified nursing assistant (CNA) A and CNA B regarding resident 13 revealed: *She was sleeping in bed. *She had her bath today and had not wanted to get up earlier. *She had behaviors especially when she got her bath. *CNA A stated last time she had given the resident a bath she had been hit a few times. -She developed a bruise on her right underarm and left forearm. *She had never liked getting a bath since she had been admitted . *One time they had given her a bath in the afternoon, and that went okay. *They had not changed her to an afternoon bath. *They had attempted to let her wake up on her own, and then gave her bath. *CNA A thought she did better if she had time to wake up. *She had not liked the water in the tub. *Other behaviors had increased in the last month. Interview on 2/6/18 at 1:24 p.m. with an unidentified CNA revealed they had gotten resident 13 up, but she had wanted to go back to bed. She did not want her bath, and she did not want to eat. They had been able to get her to eat ice cream. Observation on 2/6/18 at 3:23 p.m. of resident 13 revealed she was dressed and sleeping in her recliner with music on. Review of resident 13's current undated care plan revealed there had been nothing addressed regarding her behaviors during her bath. Interview on 2/7/18 at 3:42 p.m. with the director of nursing, the administrator, and resident care coordinator (RCC) A regarding resident 13 revealed: *They were aware of her having behaviors with her bath. *RCC A stated she did not like the water in the bottom of the tub. -She thought it scared her. *They stated they had attempted different interventions but had not documented them. *They were not aware the behaviors surrounding bath time had not been addressed on the care plan. *They stated staff should have intervened on 2/5/18 when she was yelling at her table mate in the dining room. *The CNAs would document behaviors in the Kiosk, but they were not resident specific, they were connected to the MDS assessment. *There had been no other documentation of other interventions attempted to reduce her anxiety and behaviors at bath time. 2. Review of resident 62's medical record revealed: *She had been admitted on [DATE]. *Per her fall risk evaluation she had been at high risk for falling. *She had fallen on 11/21/17, 12/9/17, and 12/21/17. *Her [DIAGNOSES REDACTED].>-Demetia without behavioral disturbances. -[MEDICATION NAME] degeneration. -Major [MEDICAL CONDITION]. Review of resident 62's 10/18/17 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status (BIMS) score of eight indicating her cognition was moderately impaired. *There had been no behaviors noted. *She required the extensive assistance of one staff person to transfer and to walk in the corridor. *She was frequently incontinent of urine and occasionally incontinent of bowel. *She was on scheduled pain medications. *She had no falls prior to admission. *She was on a diuretic and was getting minimal physical therapy. Review of resident 62's 1/2/18 MDS revealed: *Her BIMS score was six indicating her cognition was severely impaired. *She had two or more falls with injury. Interview on 2/6/18 at 10:18 a.m. with resident 62's son revealed: *She had three falls since her admission. *He was unsure of the dates, but she had to be sent to the emergency room (ER) once. *One other time she had hit her head. *She liked to sleep in her recliner due to back pain. *She had a current urinary tract infection and was receiving an antibiotic. -He believed she was just finishing up with it. Observation on 2/6/18 at 10:30 a.m. of resident 62 revealed she had been sleeping in her recliner in her room. Review of resident 62's current 1/9/18 care plan revealed: *A problem area of high risk for falls included with alteration in activities of daily living initiated on 10/31/17 and reviewed on 1/9/18. *The goal was Resident will have no falls. *Interventions related to falls had included: -Do not leave alone in bathroom, initiated on 11/1/17. -Keep room uncluttered, initiated on 10/31/17. -Restorative program: active range of motion, initiated on 11/9/17. *There had been no other interventions listed for falls on the care plan. Interview on 2/7/18 at 3:42 p.m. with the administrator, the director of nursing, and resident care coordinator A regarding resident 62 revealed: *She had been identified at high risk for falls upon admission. *They were aware of her visual impairment. *After she had fallen on 11/21/17 they stated they had reminded her to wait for help to ambulate. -They agreed residents with dementia might not remember to do that. *They had also moved her trash can closer. *They had identified interventions after the falls had occurred but had not assessed her environment prior to the falls. 3. Interview on 2/7/18 at 3:42 p.m. with the director of nursing, the administrator, and resident care coordinator A revealed the care plans for residents 13 and 62 had not been updated to reflect their current needs. Review of the provider's 3/9/16 Care Plan - Comprehensive policy revealed care plan interventions were to be designed after careful consideration of the relationship between the resident's problem areas and their causes.", "filedate": "2020-09-01"}
{"rowid": 17, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2018-02-07", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TWBV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to accurately document one of one sampled resident's (7) current situation related to a medication change that had not occurred. Findings include: 1. Review of resident 7's medical record revealed on 2/6/18 the care conference note stated her [MEDICATION NAME] had been decreased in (MONTH) (YEAR) and the [MEDICATION NAME] had been decreased in (MONTH) (YEAR). Interview on 2/7/18 at 3:42 p.m. with the director of nursing (DON), the administrator, and resident care coordinator (RCC) A regarding resident 7 revealed: *They had just discussed the decrease in medication from (MONTH) (YEAR) this past week. *They felt the resident had been exhibiting more behaviors, and they had contacted the physician for her to be seen the next time rounds were done. *They felt the medication needed to be adjusted again and for it to go back to what it was prior to December. *Documentation was requested from the DON at that time for monitoring the effectiveness of both medication changes. Interview on 2/7/18 at 4:00 p.m. with RCC A revealed there had not been a medication change of the [MEDICATION NAME] in (MONTH) (YEAR). She had documented inaccurately in the care conference note. She had looked at the physician order [REDACTED]. She realized after reviewing the chart again the only change to the order had been Do not crush. Adding that phrase changed the date on the order to 12/4/17. She had assumed based on that date the medication had been reduced which was inaccurate. Review of [NAME] [NAME] Potter and Anne Griffen Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), p. 356, revealed: *Documentation is a nursing action that produces a written account of pertinent patient (resident) data, nursing clinical decisions and interventions, and patient responses in a health record. *Nursing documentation needs to be accurate and comprehensive.", "filedate": "2020-09-01"}
{"rowid": 18, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2018-02-07", "deficiency_tag": 689, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TWBV11", "inspection_text": "Based on observation, interview, and record review, the provider failed to assess the environment and implement interventions for one of one sampled resident (62) who had been identified to be at risk for falls upon admission. Findings include: 1. Review of resident 62's medical record revealed she had been identified to be at high risk for falls, and the provider had not assessed the environment and implemented interventions for the falls. Refer to F657, finding 2.", "filedate": "2020-09-01"}
{"rowid": 19, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2018-02-07", "deficiency_tag": 740, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TWBV11", "inspection_text": "Based on observation, interview, and record review, the provider failed to ensure one of one sampled resident (13) with behaviors and anxiety received the appropriate care and services. Findings include: 1. Review of resident 13's medical record revealed she had been identified to have behaviors that affected others and behaviors revolving around her bath. The provider failed to implement and document appropriate interventions. Refer to F657, finding 1.", "filedate": "2020-09-01"}
{"rowid": 20, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 550, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the provider failed to ensure: *One of one sampled resident (61) was engaged in conversation during three of three meal services. *Two of two sampled residents (61 and 78) were provided privacy during personal care. Finding include: 1. Review of resident 61's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Unspecified dementia without (w/o) behavioral disturbances. -Age related [MEDICAL CONDITION] w/o current pathological fracture. -Hypertension. -Vitamin D deficiency. Review of resident 61's 4/2/19 Minimum Data Set assessment revealed: *There was no Brief Interview for Mental Status assessment score due to significant cognitive impairment. *The resident representative was not available for an interview for her daily activity preferences, and the resident was not able to be interviewed. *She was totally dependent upon two staff for assistance with bed mobility, transfers, toilet use, and bathing. *She was totally dependent upon one staff person for locomotion on and off the unit. *She required the extensive assistance of two staff for dressing and personal hygiene. *She required the extensive assistance of one staff person for eating. Observation on 5/7/19 from 7:50 a.m. through 8:27 a.m. in the [NAME] wing dining room revealed: *Certified nursing assistant (CNA) F and CNA G were sitting at dinning room table four. -They were sitting on opposite corners of the table to assist residents with breakfast. *There were four residents sitting at the table needing assistance including resident 61. *CNA F and G were maintaining a conversation between themselves across the table. *CNA G did tell resident 61 what was on her fork one time. *There was no other verbal communication with the resident's by either CNA during that time. Observation on 5/7/19 from 12:18 p.m. through 12:25 p.m. in the [NAME] wing dining room revealed: *CNA G and H were sitting at dining table four. *They were sitting on opposite corners of the dining room table to assist residents with lunch *There were four resident's sitting at the table needing assistance including resident 61. *CNA G and H were maintaining a conversation between the themselves, from across the table. *No observations were made of staff talking to the residents during that time. Interview on 5/9/19 at 9:14 a.m. with CNA F revealed: *It was normal for her to talk to the residents about what they were eating when she was assisting them. *She explained to them what they were eating and when she was giving them a bite. *She did not typically engage in conversations with other staff members sitting at the tables. Interview on 5/9/19 at 9:47 a.m. with CNA G revealed: *She told the residents what was on their plates when assisting them with eating. *She would watch the resident's facial expressions to know likes and dislikes. *She would offer fluids after two bites of food. *She did not typically engage in conversation with with other staff while assisting residents to eat. Interview on 5/9/19 at 9:52 a.m. with the director of nursing (DON) revealed: *The expectation was for the CNAs to interact with the residents when they were assisting them with their meals. *It was not acceptable to have minimal interaction with residents and conduct a conversation among themselves. 2. Observation on 5/8/19 from 8:16 a.m. until 8:23 a.m. of resident 61 revealed: *Licensed practical nurse (LPN) N entered her room after knocking on the door, and resident 61 was laying in bed. *LPN N elevated head of her bed, and then swabbed out her mouth. *LPN N had not provided privacy for her. The door was not closed, and the curtains were left open. *CNA F entered the room with her breakfast tray. *CNA F was standing next to her bed assisting her with eating breakfast. *CNA F stood next to her bed until she left the room [ROOM NUMBER] minutes after entering the room. Interview on 5/9/19 at 10:22 a.m. with the DON regarding resident 61 revealed: *LPN N should have provided privacy for the resident when she performed oral care. *CNA F should not have stood over the resident to assist her with eating. Surveyor: 3. Observation on 5/07/19 at 8:54 a.m. of resident 78 revealed: *The DON and CNA M assisted the resident to the restroom using the mechanical standing lift. *The curtain had not been pulled around her roommate's bed, and the bathroom door had not been closed. *Her roommate was resting in her bed. *Her roommate could have watched her while: -Staff exposed her while in the standing lift. -Being transferred to the toilet. -Sitting on the toilet. -Staff had provided perineal care that would have been visible to the roommate or anyone else that could have entered the room. Surveyor Interview on 5/8/19 at 8:54 a.m. with the DON regarding the above observation of resident 78: *The curtain should have been pulled or the bathroom door should have been closed. *She agreed the roommate could have seen someone using the restroom if the curtain was not pulled, or the door was not closed. Review of the provider's 3/31/17 Quality of Life - Dignity policy revealed: Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.", "filedate": "2020-09-01"}
{"rowid": 21, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 574, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure the ombudsman and South Dakota Department of Health information had been posted in a location accessible to the residents, visitors and families. Findings include: 1. Interview with the resident group on 5/8/19 from 10:00 a.m. through 10:30 a.m. revealed: *The residents were unaware of where to find contact information for the Ombudsman. *The residents were not aware they could contact the South Dakota Department of Health directly. Observation on 5/8/19 between 12:30 p.m. and 3:00 p.m. revealed: *The ombudsman's contact information was posted in the foyer of the front door. -The resident's were not able to access this without the assistance of staff. The door from the inside of the building required a code to open. *The ombudsman's contact information was also posted down [NAME] wing on a door. -That information was at eye level when standing. -It would not have been accessible to read from a wheelchair. Interview on 5/8/19 at 11:40 a.m. with the regional ombudsman revealed: *She had asked for the ombudsman information to have been placed down each hallway. *She had asked for the ombudsman information to be more available to the residents. *The ombudsman contact information was only available in the foyer, that had a secured door from the inside of the facility going out into the foyer. Interview of 5/8/19 at 2:48 p.m. with the social service director and the social service assistant P revealed: *There were cards in their office for the ombudsman and the poster was in the foyer. *They agreed the residents could not access the poster with the ombudsman's contact information. Interview on 5/8/19 at 2:58 p.m. with the administrator revealed: *The ombudsman's contact information was posted in the front foyer and on [NAME] wing by the back door. *She agreed residents would need help to access the ombudsman's contact information in the foyer. *She was not aware of the ombudsman asking the facility to have her contact information more accessible. Review of the provider's 3/31/18 Resident Rights policy revealed: Resident's have the right to Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protections or advocacy organizations, ect.) regarding any matter.", "filedate": "2020-09-01"}
{"rowid": 22, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 584, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure: *One (hallway A) of four hallways was clean and in good repair. *Mechanical lifts stored in resident's rooms in one of four hallways (E wing) had prevented residents access to their items. Findings include: 1. Observation on 5/9/19 from 7:20 a.m. through 9:00 a.m. of residents' rooms (513, 514, 515, 516, 517, and 518) revealed: *There were between three and ten tan tiles in the door way of each resident's room. -There was approximately 1/8 to 1/4 inch gap between the tan tiles in the door ways and the white tiles in the rooms. -Dust and grime could be scraped out of those gaps with a fingernail. -Dust build-up in the corners of each door way that could be wiped off the floor. -One door way was rusted at the bottom and had started staining the tiles that were next to it. -One door had three gouges across the bottom of the door deep enough that no varnish remained. -There was a white substance splattered on two of the six doors approximately one fourth of the way up and all the way across the bottom. -There were two rooms that had tiles cracking along the top of the tiles. *There were five residents' rooms with brown plastic protectors on the doors. -They were secured to the doors with fifteen screws. -They were not sealed and left gaps between the door and the plastic piece. -The edges of the plastic were sharp. -One plastic piece was broken on the corner under the screw that was holding it to the door. Interview on 5/9/19 at 8:41 a.m. with the head of housekeeping and laundry revealed: *They had been short staffed in housekeeping with only two housekeepers to clean the entire facility. *With only having two housekeepers for the facility they had not been able to get all of the cleaning done. *They had made residents' rooms and dining rooms their priority for cleaning. *The white splatter on the doors was floor wax, and she had been unable to get it cleaned off the doors. Interview on 5/9/19 at 8:49 a.m. with the maintenance man revealed: *The hallway floors were cleaned by a floor machine daily. *Residents' rooms were mopped daily. *There was no schedule for deep cleaning the floors. *The plastic pieces on the doors were replaced quarterly when the maintenance report was generated. -He agreed they were not sealed and could not be cleaned behind. -He would replace the plastic pieces as needed when he noticed they were in poor repair. -He agreed the plastic pieces with wax on them should have been replaced if they could not be cleaned. *He agreed it was dirty in the gaps between the tiles in the rooms. *He agreed that one door frame was dirty and rusty. 2. Interview on 5/8/19 at 9:02 a.m. with CNA F revealed: *Mechanical lifts were generally stored in residents' rooms, because they had no where to store them. *They were generally stored in front of the closet doors. -They would have needed to be moved to open the closet. *Those lifts were used for several residents. *Resident 78 usually had a mechanical lift stored by her bed. -Several residents used that lift. Interview on 5/8/19 at 10:54 a.m. with resident 78 revealed: *She usually had a mechanical lift stored on her side of the room. *Staff used that lift to transfer her along with several other residents. *She had a Brief Interview for Mental Status (BIMS) of fifteen. She was cognitively intact. *She was able to get around the room in her wheelchair. *She did not have access to her night stand or her bed while the lift was stored in her room. *She preferred not to have the lift stored in her room. 3. Interview on 5/7/19 at 9:11 a.m. with CNA K regarding the mechanical lift stored in resident 24's room revealed: *That lift was not used by anyone in that room. *It got pushed in there out of the hallway. *They had removed the lifts from the hallways because the surveyors were here. Observation and interview on 5/8/19 at 9:18 a.m. with the resident care coordinator in resident 24's room revealed: *There was a mechanical lift stored in the far corner of the room. -It was stored in front of the closet doors. -It would have needed to be moved to open the closet door. *The resident care coordinator stated: -Lifts were kept in the resident's room. -She had been told from the beginning that it was an acceptable place to keep them. -At times the lifts would be kept in the hallways. Surveyor Review of the provider's 11/26/18 Homelike Environment policy revealed: *Resident's are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. *The Facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment.", "filedate": "2020-09-01"}
{"rowid": 23, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and protocol review, the provider failed to ensure documentation was completed for one of four sampled residents (18) who had a pressure ulcer. Findings include: 1. Review of resident 18's medical record revealed: *A telephone order dated 1/27/19 at 4:30 p.m. from a physician (name). *Order stated to apply Allevyn to opened area on the coccyx. -Change every (q) three days and as needed (PRN) until healed. *Minimum (MDS) data set [DATE] indicated a stage 2 pressure ulcer. *There had not been any: -Additional nursing progress notes regarding that pressure ulcer. -Documentation of notification to the family or physician. -Measurements of the pressure ulcer. -Weekly skin assessments. -Initial event report. *Review of a 2/12/19 at 12:40 p.m. interdisciplinary progress note revealed: *Category: Skin assessment, physician visit. -Primary care physician (name) was there for an acute visit and assess the coccyx/buttock pressure sore. -Buttock is chapped, dry peeling skin with an open area mid coccyx noted. -Allevyn dressing changed after assessment completed. Interview on 5/08/19 at 9:50 a.m. with the director of nursing (DON) regarding resident 18 revealed: *The DON confirmed the above findings. *She saw a telephone communication from the physician dated 1/27/19 that stated to change the dressing q 3 days or as needed if it came off. *Based on that information she believed the pressure ulcer to the resident's coccyx had started on that date. *She stated she did not know why there had not been: -An initial event report. -Documentation in the pressure ulcer log. -Documentation of notification to the physician. -Documentation of notification to the family. Review of the provider's revised 3/24/17 Pressure Ulcer/Skin Breakdown-Clinical Protocol revealed: *If skin breakdown or pressure ulcer was discovered, the following would be notified immediately: -Attending physician -Resident's responsible party. -Wing coordinator and/or skin team representative. *The nurse should assess and document/report the following: -Vital signs -Full assessment of the pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue. -Pain assessment. -Resident's age and sex. -Resident's mobility status. -Current treatments including support surfaces. -All active diagnoses.", "filedate": "2020-09-01"}
{"rowid": 24, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 679, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure four of seven sampled residents (24, 52, 61, and 76) had individualized and meaningful activities. Findings include: 1. Review of resident 52's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Age related [MEDICAL CONDITION]. -Vitamin D deficiency, unspecified. -Heart failure. Review of resident 52's 3/20/19 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was three indicating her cognition was severely impaired. *It was very important for her to: -Have books, newspapers, and magazines to read. -Be around animals such as pets. -Keep up with the news. -Go outside and get fresh air. -Participate in religious services. *It was somewhat important for her to: -Listen to music. -Do things with groups of people. -Do her favorite activities. Review of resident 52's current undated care plan revealed her interventions for activities were: *Inform of daily activities and assist with wheelchair to and from activities of choice. *Activity group interests: games (BINGO), crafts, parties, religious activities Methodist. *Leisure activity interests: TV, visiting, phone, watching/listening to sports. Observation on 5/7/19 at 3:00 p.m. and again at 4:02 p.m. of resident 52 revealed: *She was sitting in her recliner in her room and was awake. -There was no television in her room, and there was no music playing. *At 3:00 p.m. there was a puzzle activity going on in the Independence dining room. *At 4:00 p.m. they were gathering residents for another activity in the Independence dining room, but she had not been invited. *She had not participated in either of those activities. Interview on 5/7/19 at 4:25 p.m. with resident 52 in her room revealed: *The activity staff person did not come in to ask her to join the activity. *There had been no TV in her room, and there was no music on. *She stated she liked to watch TV. *She used to have a TV, but was not sure where it had gone. Observation on 5/7/19 at 5:43 p.m. of resident 52 revealed she was still sitting in recliner in her room and was awake. Observation on 5/8/19 from 7:51 a.m. through 10:41 a.m. of resident 52 revealed: *She was in her room sitting up in her wheelchair. -Her head was hanging down, and her eyes were closed. *At 7:55 a.m. she was taken into the dining room for breakfast. *At 9:43 a.m. she was in her room sitting in her chair with the newspaper on her lap. -Her head was hanging down, and her eyes were closed. *At 10:41 a.m. she was still sitting in her chair in her room with her eyes closed. Interview on 5/8/19 at 2:54 p.m. with social services assistant/activity assistant P revealed: *Her primary responsibility was completing one-to-one activities with the residents. *It could be anything but usually she visited with the residents. Observation on 5/8/19 at 3:47 p.m. of resident 52 revealed: *She was laying in bed sleeping. *At that time they had a gentleman singing in the Independence dining room. Review of resident 52's activity documentation revealed: *In (MONTH) 2019: She had four out of eighteen days documented for activities. *In (MONTH) 2019: She had seven out of thirty days marked for activities. *In (MONTH) 2019: She had two out of six days marked for activities. Interview on 5/9/19 at 8:21 a.m. with the activity director regarding resident 52 revealed: *She was supposed to have one-to-one programming three times per week. *She personally did not ask her to attend yesterdays activity. *She was not aware the resident liked to watch TV. *The social services assistant/activity assistant P provided the one-to-one activities. -She was unavailable to interview that morning. *She could participate in group activities, but staff would have to ask her to join. They were not asking her regularly. Interview on 5/9/19 at 8:41 a.m. with the social services director revealed: *Resident 52 had come into the facility on Medicare. *The Medicare rooms had TVs in them. *She had to move out of that room when she was no longer on Medicare. *The room they moved her into did not have a TV, and the resident or family would have to provide their own. *They were unsure if the family was going to provide one or not. *There were other areas in the building she could have watched TV, but they had not taken her there. 2. Review of resident 76's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbance. -[MEDICAL CONDITION]. -Malignant neoplasm of prostrate. -Other retention of urine. Review of resident 76's 1/16/19 MDS revealed: *He had long and short term memory problems. *The staff interview had been completed for his preferences that included: -Listening to music. -Being around animals such as pets. -Doing things with groups of people. -Participating in favorite activities. -Participating in religious activities. Review of resident 76's current undated care plan revealed his interventions for activities were: *Inform of daily activities assist with wheelchair assist with directions assist with transfers. *Activity group interests: Bingo, parties, religious activities Catholic activities. *Leisure activity interests: Reading group, TV, visiting, radio. Review of resident 76's activity documentation revealed: *In (MONTH) 2019: He had nine out of thirty-one days documented for activities. *In (MONTH) 2019: He had twelve out of thirty days documented for activities *In (MONTH) 2019: He had three out of six days documented for activities. Observation on 5/7/19 at 3:00 p.m. and again at 4:10 p.m. with resident 76 revealed he was laying in bed with his eyes closed. There was no music or TV on in his room. At 4:17 p.m. the reading activity had started in the Independence dining room, but he had not been taken to it. Observation on 5/8/19 at 9:45 a.m. and again at 10:41 a.m. of resident 76 revealed he was sitting in his chair in his room. He was sleeping. Interview on 5/9/19 at 8:31 a.m. with the activities director regarding resident 76 revealed staff were to assist him to activities. He should have been invited to the reading activity. 3. Review of Resident 61's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbances. -Age related [MEDICAL CONDITION] without (w/o) current pathological fracture. -Hypertension. -Vitamin D deficiency. Review of resident 61's 4/2/19 MDS assessment revealed: *There was no BIMS assessment score due to significant cognitive impairment. *Resident representative was not available for an interview for her daily activity preferences, and the resident was not able to be interviewed. *She was totally dependent upon two staff for assistance with bed mobility, transfers, toilet use, and bathing. *She was totally dependent upon one staff person for assistance with locomotion on and off the unit. *She required the extensive assistance of two staff for dressing and personal hygiene. *She required the extensive assistance of one staff person for eating. Observations of resident 61 on 5/7/19 at the following times revealed: *At 8:40 a.m. she was in her wheelchair in her room with her son. -She had no TV or radio in her room. *From 9:37 a.m. until 10:06 a.m. she was in her wheelchair in the hallway sitting next to the wall. *From 3:00 p.m. through 4:25 p.m. she was resting in her room in bed with the light off. -There was a reading activity going on in the dining room at 4:00 p.m. Review of resident 61's activity logs from 3/26/19 to 5/6/19 revealed: *There were forty-four days with opportunities for activities. *There had been twenty-one days she had no activities provided to her. *She had attended seventeen reading groups. *She had attended five religious activities. *She had been provided with seven one-to-one activities. Review of the provider's (MONTH) 2019 and (MONTH) 2019 activity calendars revealed: *Between (MONTH) 1, 2019 and (MONTH) 8, 2019: -Reading group was offered twenty-eight times. -There were forty-five religious activities offered. Review of resident 61's 5/8/19 care plan revealed: *She had altered participation in activities due to cognitive impairment. *She was to passively participate in group activities one to two times per week. -Her group activity interests included music, parties, religious activities, and communion. *She was to have leisure activities daily. -Her leisure activity interests included reading group and visiting with family. Interview on 5/9/19 at 10:28 a.m. with CNA/activities coordinator C regarding resident 61 revealed: *They had recently had eighteen admissions from another facility, and she was still getting to know those residents. *She was providing the resident with one-to-one activities three times per week. *She indicated the resident spent a lot of time in bed resting. *She indicated the resident would attend reading group when it was offered. *She stated she needed to look at the way activities were implemented on [NAME] wing. 4. Review of resident 24's 2/26/19 MDS assessment revealed: *She had a short-term memory deficit. *Verbally and non-verbally she was rarely/never understood. *Sometimes understood, and responded adequately to simple, direct communication only. *She was totally dependent on staff assistance for bed mobility, transferring, locomotion on the unit, dressing, eating, using the bathroom, and personal hygiene. Interview on 5/9/19 at 10:12 a.m. with CNA C regarding resident 24 revealed: *They tracked their one-to-one activities. *They did not keep track of the amount of time they spent with the residents on their one-to-one activities. *She stated that there was no way to tell how long they had spent with each resident with their current documentation. Review of resident 24's 10/31/17 care plan revealed an intervention for one-to-one visits three times a week. 5. Interview on 5/08/19 at 9:04 a.m. with social services assistant P revealed: *She completed all one-to-one activities. *She would document the activities into the activities detail report in the computer. *There were no entries of the amount of time spent with resident's for one-to-one activities. *She was unaware she needed to document the amount of time she was spending with each resident. Interview on 05/09/19 at 8:29 a.m. with the DON revealed she could not say how long the one-to-one activities lasted by reviewing their current documentation. Review of the 11/14/17 Individual Activities and Room Visit Program policy revealed: *A room visit was seven to fifteen minutes in length. *It was the responsibility of the facility and the activity staff to make regular contacts and offer supplies as needed. Review of the provider's 11/14/17 Activity Program policy revealed: *Activity programs designed to meet the needs of each resident were available on a daily basis. *Activities would encourage the maximum individual participation and be geared toward individual resident needs. *Activities would be scheduled seven days per week. *Individualized group activities were provided that reflected schedules, choices and rights of residents.", "filedate": "2020-09-01"}
{"rowid": 25, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2019-05-09", "deficiency_tag": 880, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L4FS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure appropriate hand washing was done for: -One of two residents (89) wound care observations preformed by wound care nurse I . -Two random residents (18 and 42) during perineal care performed by certified nursing assistants (CNA) K, L, and M. *Provide appropriate catheter care for one of two residents' (144) observed catheter care done by CNAs A and B. *Identify and implement transmission-based precautions for one of one sampled resident (92) to prevent the spread of infection. *Follow cleaning procedure for two of three observed tub cleanings (D and [NAME] wings) by CNAs D and E. *Properly store tub disinfectant chemicals and personal care items in all four tub rooms. *Properly clean mechanical lifts between residents' (51, 78, and 85) use for two of two missed mechanical lift cleaning opportunities done by CNAs M and O. Findings include: 1. Observation and interview on 5/8/19 from 2:52 p.m. through 3:17 p.m. with wound care nurse I regarding resident 89 revealed she: *Had been seeing her since last September. *Stated she had used hand sanitizer when she entered the room. *Assisted repositioning the resident as the pressure ulcer was on her coccyx. *Gloved and took off the resident's soiled dressing. *Took out supplies from her canvas bag. *Measured depth with a Q-tip. -Took her pen out of her bag and wrote down measurements on a paper. *She continued with the same gloves on and cleansed the wound with one 4 x (by)4 sponge and wound cleanser. -Wiped several times over the wound. *Packed her wound with one 2x2 sponge pad, ointment applied with a Q-tip. *Opened and applied a [MEDICATION NAME] dressing to the wound. *Removed her gloves. *Cleaned up the area, threw away garbage, and put supplies in a plastic Ziploc bag in her canvas bag. *Then she put gloves on and pulled up the her pajama pants. *Moved the bed back in place. *Touched the resident's head and neck area and moved her pillow for comfort. *Took off her gloves. *Opened a chocolate kiss and placed it directly into the resident's mouth. *Finished her paperwork using that same pen. *Wiped off the camera, flashlight, pen, and scissors with a sani-cloth wipe. -Sani-cloth wipe instructions were to air dry for three minutes. -Put items directly in her bag. *Applied hand sanitizer to her hands. Interview on 5/8/19 at 3:56 p.m. with wound care nurse I revealed: *It was her practice to use hand sanitizer before and after a procedure. *She did not have to wash her hands with glove changes or before or after a procedure. *She would have followed the policy of her employer. Interview on 5/8/19 at 4:17 p.m. with the director of nursing (DON) concerning the above procedure revealed: *Hand washing would have been expected: -When entering the room. -After removing dressings. -Any time gloves were changed. -After documentation. -Before assisting with a chocolate candy. -She should have followed the nursing homes policy for wound dressing changes. Review of the provider's (MONTH) 2013 Dressings, Dry/Clean policy revealed: *Position resident and adjust clothing. *Wash and dry your hands thoroughly. *Put on clean gloves. *Loosen tape and remove soiled dressing. *Pull glove over dressing and discard into plastic bag. *Wash and dry your hands thoroughly. *Open dressings. *Put on clean gloves. *Assess the wound. *Cleanse the wound using a clean gauze for each cleansing stroke. *Use a dry gauze to pat the wound dry. *Apply the ordered dressing. *Discard disposable items. *Remove your gloves. *Wash and dry your hands thoroughly. *Reposition the bed covers and make the resident comfortable. 2. Observation and interview on 5/7/19 at 11:25 a.m. of CNA M revealed: *She took the standing lift out of resident 85's room and took it to resident 78's room for storage without cleaning it. *It was stored directly over resident 78's bed. *She stated it was not routine to disinfect the lifts when taking them from room-to-room. *That lift was generally stored in resident 78's room. Observation and interview on 5/7/19 at 4:59 p.m. with CNA O revealed she: *Had transferred resident 51 using the standing lift from resident 78's room. *She stated she had taken it back into resident 78's room because she needed more room in resident 51's room. *She had not disinfected the lift. *The lift was placed directly over resident 78's bed. *Both of the above rooms were double rooms and had minimal space. Interview on 5/8/19 at 4:23 p.m. with the DON regarding the cleaning of mechanical lifts between resident use revealed: *The lifts were stored in the residents' rooms that used it the most frequently. *They would need to be wiped off only if they were visibly soiled. Review of the provider's (MONTH) 2013 Cleaning and Disinfection of Resident Care Items and Equipment revealed: *Reusable items were cleaned and disinfected between residents. -That included durable medical equipment. 3. Observation on 5/8/19 at 7:20 a.m. of certified nursing assistants (CNA) A and B during catheter care for resident 144 revealed CNA A: *Washed her hands and set up the necessary equipment at the resident's bedside. *Removed the resident's brief. *Washed her hands, put gloves on, and prepared washcloths with skin cleanser. *With those gloves on she used a washcloth to clean the resident's left and then right groin areas. Using the same washcloth she: -Turned the cloth over and without separating the labia to expose the catheter insertion site she wiped the catheter tubing from the area where the labia and tubing met down the tubing to approximately nine inches below the labia. -Placed that soiled washcloth in a plastic collection bag. She then: *Picked up a clean soapy washcloth. *Performed the perineal care in the same manner washing the left and then right groin, then turning the cloth over and without opening the labia to expose the catheter insertion site, used the same cloth to wipe off the catheter tubing from the labia to approximately nine inches below the labia. *Placed that soiled washcloth in the collection bag. *Picked up a clean soapy washcloth. -Used that washcloth to clean the resident's bottom after CNA B assisted the resident to turn on her side. *Removed her gloves and washed her hands. *Assisted the resident to dress. Interview with the DON on 5/9/19 at 2:09 p.m. regarding the above catheter care observation confirmed the following. She would have expected the CNA to separate the resident's labia and clean around the catheter insertion site for catheter care. Review of the provider's (MONTH) (YEAR) Urinary Catheter Care policy revealed: *The employee was to have washed her hands and put on gloves. *With nondominant hand separate the labia of the female resident. *Maintain the position of this hand throughout the procedure. *Use a washcloth with warm water and soap to clean the labia. Use one area of the washcloth for each downward, cleansing stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. *Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward. 4. Observation on 5/17/19 at 11:57 a.m. with CNAs K and L while performing perineal (peri) care for resident 18 revealed: *They brought an EZ lift into the room. *They had not cleaned it.*They washed their hands and put on gloves. *They both removed the brief with soiled loose bowel movement. *CNA L placed the soiled brief into the trash can. *Without removing their gloves CNA K opened the nightstand and retrieved the wet wipes. -Both CNAs rolled the resident to her left side. -CNA K performed peri-care with the wet wipes. -With the same gloves on she held the container to pull a new wet wipe out. -With those same original gloves on both CNAs rolled the resident to her opposite side. *CNA K continued to perform the peri-care. -More wet wipes were removed from the container by CNA K with the same gloves on. *CNA K then removed her gloves and without washing her hands she put on new ones. -She put barrier cream on the resident's bottom. -She removed her gloves and washed her hands. *CNA L then removed her gloves and threw them into the bathroom trash can. -Without washing her hands she took the garbage from the bathroom and placed it near the resident's room door. *Both CNAs assisted hooking the loops of the EZ lift belt to the metal bar of the lift. *CNA K ran the lift controls. *CNA L moved the wheelchair under the resident. -She straightened out the resident's clothes. -She washed her hands. *CNA K left the room with the trash and washed her hands in the utility room. *The EZ lift was removed from the room and was not cleaned appropriately. Interview on 5/18/19 at 4:39 p.m. with the resident care coordinator on [NAME] hall concerning the above care revealed: *She would have expected those CNAs to have washed their hands when coming into a room, leaving a room, and when changing gloves. *The resident was safe. There were opportunities for them to wash their hands. Interview on 5/19/19 at 9:47 a.m. with CNA K regarding the above care revealed: *She should have washed her hands more. *She should have washed her hands after removing her gloves and putting on new ones. *She knew she should have washed her hands when going into a room, in-between removing and putting on new gloves, and when leaving a room. Interview on 5/19/19 at 10:00 a.m. with CNA L regarding the above care revealed: *She should have washed her hands after removing her gloves and putting on new ones. *She knew she should have washed her hands when going into a room, in-between removing and putting on new gloves, and when leaving a room. *It must have slipped her mind. -I usually do wash my hands after removing my gloves. 5. Observation on 5/7/19 at 9:06 a.m. with CNAs K and M while performing care on resident 42 revealed: *There was an EZ stand lift in her room. *The CNAs performed hand hygiene and put on gloves. *With those gloves on they assisted the resident into the EZ stand lift. *They moved her into the bathroom. *Both CNAs helped to lower her pants and wet brief. *With those same gloves on CNA K:-Touched the stand controls and lowered the resident onto the toilet. -Opened the resident's closet and got a brief. *With those same gloves on CNA L took a washcloth, turned on the faucet, and wet and soaped it up. Then she: *Washed the resident's perineal area. *She removed her gloves and put them in the trash bag. -She did not wash her hands. *CNA K removed her gloves and did not wash her hands. *Both CNAs put a new brief on the resident and pulled up her pants. *CNA K used the controls on the EZ lift to raise her from the toilet. -She placed the resident in her recliner. -Then she washed her hands. *The EZ stand was not cleaned prior to removing the lift from the room. Interview on 5/8/19 at 4:28 p.m. with the resident care coordinator on [NAME] hall concerning the above care revealed:*She would have expected them to change gloves after they were soiled or after cleaning the peri-area. *There were opportunities for and I would have hoped they performed hand hygiene. Interview on 5/9/19 at 9:34 a.m. with CNA M concerning the above observation revealed: *She should have changed her gloves.*She should have washed her hands after doing that. Interview on 5/9/19 at 9:49 a.m. with CNA K revealed: *She should have changed her gloves more often and washed her hands each time she removed gloves. *She thought she should have gotten a small bottle of hand sanitizer and carried it with her to use between glove changes. Review of the provider's 7/11/13 Hand washing/Hand Hygiene policy revealed: *Employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: -C. Before and after direct resident contact. -H. Before and after assisting a resident with personal care. -N. Before and after assisting a resident with toileting (hand washing with soap and water). -Q. After contact with a resident's mucous membranes and body fluids or excretions. -U. After removing gloves or aprons. 8. The use of gloves does not replace hand washing/hand hygiene. 6. Review of resident 92's medical record revealed: *[DIAGNOSES REDACTED]. *Interdisciplinary progress notes from 4/29/19 through 5/9/19 revealed no progress notes related to the need for infection control practices, interventions, or infection control education. Review of resident 92's 4/24/19 Minimum Data Set (MDS) assessment revealed his Brief Interview for Mental Status (BIMS) score was twelve indicating moderate cognitive impairment. Review of resident 92's care plan printed on 5/9/19 at 8:30 a.m. revealed there were no goals or interventions related to infection control. Observations on 5/7/19 between 8:15 a.m. and 4:00 p.m., 5/8/19 between 8:00 a.m. and 9:00 a.m., and 5/9/19 between 8:49 a.m. and 11:00 a.m. of resident 92 revealed: *There was a sign outside his room indicating the need for isolation precautions. -Staff were wearing gowns, gloves, and masks when entering his room. *He ate his meals in the dining room and participated in group activities without wearing personal protective equipment (PPE). *He entered and exited his room without performing hand hygiene or using PPE. *He watched television in his room beside his roommate. *There was not a privacy curtain in the room. Interview on 5/7/19 at 5:15 p.m. with registered nurse (RN) J revealed: *She was notified by a physician on 5/3/19 that resident 92's roommate's sputum tested positive for [MEDICAL CONDITION] (MRSA). *Respiratory isolation precautions were started on that date per facility policy for resident 92's roommate. -The use of PPE was started including gowns, gloves, and masks when entering or exiting that room. *The physician was asked at that time about infection control precautions for resident 92 and she was told they were not needed. -There was no documentation to support that information. *The roommate still had a congested, harsh, productive cough but was afebrile. Interview on 5/8/19 at 8:30 a.m. with the resident care coordinator revealed: *She did not know why staff were expected to use PPE in resident 92's room and he was not. *A physician had stated resident 92 was not infected, but there was no documentation to support that information. Interview on 5/9/19 at 10:38 a.m. with the infection control nurse revealed: *Resident 92 was last seen by his physician the end of March. *Resident 92 was educated on the risk of remaining in his room after his roommate tested positive [MEDICAL CONDITION] and was given the choice to move. *She had left a message for a healthcare associated infections specialist for guidance on room placement. *It was her expectation when the nurse was advised that resident 92's roommate tested positive [MEDICAL CONDITION] that room placement recommendations for him was also discussed with the provider. -If there was no provider recommendation the director of nursing and/or the infection control nurse would be notified for guidance. *Resident 92 had been educated on necessary infection control measures. Review of the 7/11/13 Policies and Practices-Infection Control policy revealed: *1. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike. *2. The objectives of our infection control policies and practices are to: -b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; -c. Establish guidelines for implementing Isolation Precautions, incuding Standard and Transmission-Based Precautions; . Review of the 7/11/13 Isolation-Initiating Transmission-Based Precautions policy revealed: *Policy Statement: Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. -1. If a resident is suspected of, or identified as having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Control Coordinator and the resident's Attending Physician for appropriate Transmission-Based Precautions. Review of the 5/1/13 [MEDICAL CONDITION] (MDRO) policy revealed: *1. Common examples of MDRO's in long term facilities [MEDICAL CONDITION] ([MEDICAL CONDITION]/[MEDICATION NAME]-resistant Staphylococcus aureus) *6. The staff and practitioner will evaluate each individual known or suspected to have infection with a multi-drug resistant organism for room placement and initiation of Contact Precautions on a case-by-case basis. *11. Depending on the situation, placement may include the following: -a. Placement in a room with someone else who is colonized or infected with the same organism, but does not have any other infection (cohorting). -b. Placement with someone who does not have invasive devices or wounds. -c. Placement in a private room, if possible. *17. In general, health visitors and volunteers will be encouraged to wear disposable gowns and gloves during visitation. If refused, visitors will be asked to perform hand hygiene before leaving the room and will be requested to not visit with other residents. Review of the 3/14/16 Isolation-Categories of Transmission-Based Precautions policy revealed: *Contact Precautions: -2. Examples of infections requiring Contact Precautions include but are not limited to: --a. Infections with multi-drug resistant organisms (determined on a case by case basis); -3. Resident Placement --a. Place the resident in a private room if possible. --b. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). -4. Gloves and Handwashing --a. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. --c. Remove gloves before leaving the room and perform hand hygiene. -5. Gown --a. Wear a disposable gown upon entering the Contact Precautions room or cubicle. *Droplet Precautions: -2. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets {larger than 5 microns in size} that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). -3. Resident Placement: --a. Place the resident in a private room if possible. --b. When a private room is not available, residents with the same infection with the same microorganism but with no other infection may be cohorted. --c. When a private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors. -4. Masks: --a. In addition to Standard Precautions, put on a mask when entering the room or cubicle. Review of the 7/11/13 Infection Control During Visitation policy revealed: *2. Visitation during Transmission-Based Precautions is permitted. Family members and visitors who are providing care or have very close contact with the resident will be trained regarding the use of infection control barriers such as personal protective equipment. 7a. Observation and interview with CNA D on 5/7/19 at 10:51 a.m. in the D wing tub room revealed: *She was cleaning the whirlpool tub after a resident's bath. *She stated staff were expected to follow a whirlpool cleaning procedure posted in the tub room. -It stated whirlpool disinfectant solution was to remain on the tub surface for ten minutes prior to draining and rinsing the tub. *CNA D completed the whirlpool tub cleaning at 11:03 a.m. -The total cleaning time did not allow the disinfectant solution to remain on the tub surface for the required ten minutes per the whirlpool cleaning procedure. b. Observation and interview with CNA [NAME] on 5/9/19 at 9:30 a.m. in the [NAME] wing tub room revealed: *She was cleaning the whirlpool tub after a resident's bath. *She stated staff were expected to follow a whirlpool tub cleaning procedure posted in the tub room. -It stated that stated whirlpool disinfectant solution was to remain on the tub surface for ten minutes prior to draining and rinsing the tub. *She followed that procedure after she completed the last resident's bath of the day. *She did not follow that same procedure in between residents' baths. -She used less time and did not allow the disinfectant solution to remain on the tub surface for the required ten minutes per the whirlpool cleaning procedure. c. Interview on 5/9/19 at 8:45 a.m. with the infection control nurse revealed it was her expectation the whirlpool cleaning procedure posted in each tub room would be followed after each resident's bath. Review of the facility cleaning procedure for Aqua Aire whirlpool posted on the walls of the four tub rooms revealed: 5. Using a scrub brush, thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. You may also use the whirlpool disinfectant spray as needed. Let disinfectant stay on surface for 10 minutes. 8a. Observation on 5/7/19 at 10:51 a.m. in the D wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. b. Observation on 5/8/19 at 10:10 a.m. in the C wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. c. Observation on 5/8/19 at 3:29 p.m. in the [NAME] wing tub room revealed: *A shelf inside the secured storage cabinet had a permeable plastic tote that held reusable nail clippers and non-reusable nail files of residents' care items. -On that same shelf were whirlpool disinfectant spray and bottles of residents' hair care products including shampoo and conditioner. d. Observation on 5/9/19 at 7:38 a.m. in the A wing tub room revealed: *A shelf inside the secured storage cabinet had two pair of medical scissors and four nail clippers. -The nail clippers had orange colored rust at the point where a nail would be inserted to be cut. *On that same shelf were whirlpool disinfectant spray, boxed cellophane wrap, and bottles of residents' hair care products including shampoo and conditioner. -The shelf was wet when touched. Interview with CNA B at that same time revealed: *The medical scissors were used to remove bandages or gauze from a resident's body. *The cellophane protected residents' skin that was to be kept dry during bathing. *The nail clippers were used for residents' nail care. e. Interview on 5/9/19 at 8:45 a.m. with the infection control nurse revealed there was no specific expectation regarding storage of cleaning chemicals with residents' care items found in the tub rooms. Surveyor: Interview on 5/9/19 at 2:20 p.m. with the director of nursing regarding the above tub room storage areas confirmed disinfectant chemicals were not to have been comingled with personal care items.", "filedate": "2020-09-01"}
{"rowid": 26, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2016-12-07", "deficiency_tag": 281, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EGJW11", "inspection_text": "Based on observation, interview, record review, and procedure review, the provider failed to follow professional nursing standards to administer a tube feeding for one of one sampled resident (8) regarding tube placement and elevated head position. Findings include: 1. Observation and interview on 12/6/16 at 2:45 p.m. of registered nurse (RN) A working with resident 8 revealed: *He had a gastrostomy jejunostomy (G J) tube located in the abdomen. *He was lying flat in his bed. *He received a liquid nutritional supplement four times a day along with medications through the g portion of the tube, that went into the stomach. *She prepared the resident's medication and nutritional supplement. *Without checking for tube placement she gave his medication and the supplement through the G port of the tube. *She had not elevated the head of the bed to prevent possible aspiration into the lungs. Review of resident 8's medical records revealed: *His admitted was 11/10/15. *He had a stroke and was unable to swallow well. *He also took food orally. *Verification of the G J tube, and his supplement and medications were to go through the g portion of the tube. *An addition to his care plan dated 10/26/16 revealed the head of the bed was to be elevated at all times. Review of the provider's 8/16/12 Enteral Tube Feeding via Syringe (Bolus) procedure revealed: *Elevate head of bed 30-45 (degrees) (semi-Fowler's position). *Verify placement of tube. *Initiate feeding. Interview on 12/6/16 at 5:45 p.m. with the director of nursing regarding resident 8's tube feeding revealed: *She agreed the nurse should have checked the tube placement before giving anything through it. *She agreed the head of his bed should have been elevated. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo.,2013, p.1032, revealed: *Place patient in high-Fowler's position or elevate head of bed at least 30 (preferably 45) degrees. Elevated head helps prevent aspiration (Kenny and Goodman, 2010). *Verify tube placement: .", "filedate": "2020-09-01"}
{"rowid": 27, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2016-12-07", "deficiency_tag": 329, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EGJW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of nine sampled residents (11) who received an antipsychotic medication had an appropriate indication for the use of it and had an attempt at a gradual dose reduction (GDR). Findings include: 1. Review of resident 11's (MONTH) (YEAR) physician's orders [REDACTED]. *[MEDICATION NAME] 125 milligrams (mg) twice daily (BID); ordered date 12/8/15. *Donepezil [MEDICATION NAME] 10 mg one tablet at bedtime; ordered date 12/8/15. *[MEDICATION NAME] 50 mg for mood; ordered date 12/8/15. *[MEDICATION NAME] 0.25 mg one tablet twice daily (BID) for restlessness and agitation; ordered date 12/8/15. -The targeted behaviors for use of the [MEDICATION NAME]: repetitive verbalizations, smearing feces, agitation, repetitive movements. Review of resident 11's 9/7/16 through 12/6/16 behavior monitoring documentation revealed she had not exhibited any physical, verbal, or other behaviors. Review of resident 11's interdisciplinary progress notes revealed: *7/13/16 Care Conference: She has no mood or behaviors noted during this assessment period. She is receiving [MEDICATION NAME] and [MEDICATION NAME] with dx (diagnosis) Anxiety and Agitation. *7/14/16: Mood essentially stable. Can become easily irritated or flustered and can seem physically aggressive to caregiver however seems more r/t (related to) lack of comprehension and difficulty in expressing self d/t (due to) cog (cognitive) deficits. *9/22/16: Mood fairly stable .has occas (occasional) periods of mild aggression which seems to be r/t inability to express needs effectively. *9/27/16 Care Conference: She has no mood or behaviors noted during this assessment period. She is receiving [MEDICATION NAME] and [MEDICATION NAME] with dx Anxiety and Agitation. Review of physician's progress notes from (MONTH) (YEAR) through 12/7/16 revealed: *She was seen every sixty days. *No GDR had been discussed or documented. Review of resident 11's consultant Pharmacist's Medication Regimen Reviews from (MONTH) (YEAR) through (MONTH) (YEAR) revealed: *10/16/16; (Resident's name) has an order for [REDACTED]. -The response was (Resident name) is not on [MEDICATION NAME] 0.25 mg PRN. *All other monthly reviews read The medication profile was assess and no significant clinical problems were noted. -No GDR had been recommended during the past year by the pharmacist. Interview on 12/7/16 at 9:10 a.m. with the consultant pharmacist regarding resident 11 revealed she: *Would have expected a GDR annually unless the resident had a [DIAGNOSES REDACTED]. *Had recommended the PRN [MEDICATION NAME] be discontinued as a GDR. -Her records indicated it was still ordered. *Had only been the consultant for less than a year, and she thought the previous consultant had recommended the physician give a different [DIAGNOSES REDACTED]. -She would look for that documentation and get back to the surveyor with that information when it was found. -No further information was received by the end of the survey. Interview on 12/7/16 at 8:45 a.m. with registered nurse/resident care coordinator B regarding resident 11 revealed: *She had been hospitalized in a behavioral health facility in (MONTH) (YEAR). -That was when she had been started on the above medications; that was over a year ago. -The revised date of 12/8/15 for the start of the medication was because she had been hospitalized for [REDACTED]. *The PRN [MEDICATION NAME] had been discontinued in (MONTH) (YEAR). -She was not sure why the pharmacist had that order in her records. -She was not sure why the pharmacist had not seen the note during her (MONTH) review that said the resident did not have a PRN dose of [MEDICATION NAME]. -She would not have considered discontinuing a PRN order that had not been used as a GDR. *She confirmed the resident: -Did not have an appropriate indication for the use of the medication. -There was not sufficient documentation to support the behaviors warranted the medications used. *They had not pursued a GDR nor discussed it with her physician in the past year. Interview on 12/7/16 at 11:00 a.m. with the director of nursing regarding resident 11 revealed: *The resident had not had a GDR in the past year. *Their previous consultant pharmacist had always reviewed for GDR, but their new one was apparently not doing that. Review of the provider's 11/12/15 Medication Monitoring and Management policy revealed: *The medication regiment is re-evaluated on a regular basis to determine whether prolonged or indefinite use of a medication is indicated. *Antipsychotics. If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.", "filedate": "2020-09-01"}
{"rowid": 28, "facility_name": "AVANTARA HURON", "facility_id": 435020, "address": "1345 MICHIGAN AVENUE SW", "city": "HURON", "state": "SD", "zip": 57350, "inspection_date": "2016-12-07", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EGJW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to follow appropriate infection control technique: *Upon entering and before exiting on of one randomly observed resident's (2) room by staff development coordinator B and dietary aide C. *During one of four sampled resident's (2) observed dressing change. Findings include: 1. Observation on 12/5/16 at 4:20 p.m. on B-wing during initial tour revealed: *Resident 2's room had an isolation cart that sat directly outside the door. *There was a note on that door to check with nursing staff prior to entering. *Staff development coordinator B and dietary aide C were observed entering the resident's room without washing their hands. *Staff development coordinator B answered a question for the resident and washed her hands upon exiting the room. *Dietary aide C had been delivering fresh water to all the residents on B-wing. *He removed the resident's water mug that had been sitting on her bedside table, walked out of her room, and placed it on a cart. *Dietary aide C had not performed hand hygiene before he left the resident's room. *He then proceeded to enter the next resident's room without sanitizing or washing his hands. *He removed that resident's water mug and placed it on the cart. *He then grabbed a fresh water mug, entered that resident's room again, and replenished the resident with a new water mug. Interview immediately following the above observation with registered nurse (RN) D regarding the above isolation room in the B-wing revealed: *Resident 2 was on contact isolation precautions for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE). *It was isolated to the resident's urine. 2. Observation on 12/6/16 at 10:10 a.m. with RN A while she performed a dressing change on resident 2 revealed: *She retrieved a bag of dressing supplies from the medication cart outside the resident's room. *She then put on a gown. *There was a hand sanitizer dispenser mounted on the wall adjacent to the door. *There were gloves available on the isolation cart located outside the resident's room. *She had not used the hand sanitizer that was readily available. *She picked the gloves up from the box on the cart and carried them inside the room. *She set the clean gloves down next to the sink. *She then washed her hands in the sink and put on gloves that she carried from the cart in her unwashed hand. *The resident was seated in her recliner. *She placed a paper towel down on the far side of the resident's bedside table and placed the plastic bag of dressing supplies on it. *She instructed the resident use her forward wheeled walker to pull herself up to a standing position. *RN A then pulled the resident's pants and brief down. *There was visible bowel movement (BM) and urine stains on her brief. *RN A proceeded to remove the dressing on her coccyx. *She had the resident sit again, went to the sink, washed her hands, and put on new gloves. *She gathered wet washcloths and wound wash. *Once more the resident stood. *RN A proceeded to wash the resident's buttocks of the BM and urine. *She placed the soiled washcloths on the bedside table, turned back to the resident, pulled her brief forward, and had the resident sit back down on the mattress protector that was on her chair. *RN A removed her gloves, washed her hands, put on new gloves, and gathered a brief. *Once more she had the resident stand. *She then applied a barrier cream with her gloved hand to the resident's buttocks and replaced the brief. *She pulled up the resident's brief with her soiled gloves and helped the resident walk to her bed from the chair. *The resident complained of shortness of breath, so she grabbed the resident's oxygen tubing with her soiled gloves. *She applied the residents oxygen tubing to her face via nasal cannula and turned the machine on with her soiled gloves. *She told the resident to lie down and grabbed her legs, helping her put them on the bed. *She moved the resident's walker out of her way using her soiled gloves. *The resident had a decorative oven mitt on her walker that fell when RN A moved it. *She retrieved it from the floor and placed it back on the resident's walker wearing the soiled gloves. *She walked to the garbage, removed her gloves, and washed her hands. *She then put on a clean pair of gloves and retrieved a clean garbage bag, and placed the soiled washcloths in it. *There was a visibly wet spot on the bedside table where the soiled linen had laid. Further observation and interview with RN A immediately following the above dressing change revealed: *She proceeded to walk out of the resident's room still wearing the isolation gown. *She opened the soiled utility room door with her soiled gloves. *She emptied soiled linen from the garbage bag into the hamper with the other resident's clothing and linen. *She walked back into the resident's room. *She removed her gown and gloves and washed her hands. *She then grabbed the dressing supply bag and moved them to the area on the bedside table where the soiled washcloths had laid. *She then grabbed the isolation garbage the gowns and gloves were in, tied the bag, and carried it down the hallway. *She came back to the resident's room and placed a new garbage can liner in the garbage can. *She grabbed the resident's dressing supplies and left the room. *She returned the resident's dressing supplies to the medication cart. *Those supplies were then co-mingled with other residents' dressing supplies. *RN A stated she frequently did dressing changes with residents in standing positions, as it was easier. *She agreed she should have followed appropriate infection control technique to avoid cross-contamination during dressing changes or when coming in contact with infectious material. Interview on 12/6/16 at 10:40 with the director of nursing regarding the above observation and interview revealed: *She was not aware hand hygiene was to have been performed when entering and upon exiting an isolation room per their policy. *She thought it had been dependent upon the type of isolation precautions needed. *It was her expectation: -All isolation linen should have been in a red biohazard bag. -Soiled washcloths should not have been placed directly on the bedside table. -All environmental surfaces should have been appropriately cleaned and disinfected after potential contamination. -Personal protective equipment (PPE) such as gowns and gloves should have been put on before entering an isolation room and removed before exiting. -The mattress protector on the chair should have been changed after contamination from the resident's bare skin. -Cross-contamination had occurred during the above observations involving RN [NAME] Review of the provider's current undated Handwashing/Hand hygiene policy revealed employees must wash their hands or perform hand hygiene before entering and after exiting isolation precaution settings. Review of the provider's current undated Isolation Precautions policy regarding: *Gloves and handwashing revealed: -Gloves were to have been worn when entering the room. -Change gloves after having had contact with infective material such as BM. -Staff were to have removed gloves before leaving the room and washed hands immediately or used a hand sanitizer. -Staff were not to have touched potentially contaminated environmental surfaces or items inside the resident's room. *Gowns were to have removed and hand hygiene performed prior to leaving the resident's room. Review of the provider's current undated Multi-Drug resistant Organisms policy revealed: *Non-critical care items (such as a water mug) was to have been been dedicated for individual use. *The infection control coordinator (staff development coordinator B) was to have monitored environmental services for compliance with cleaning and disinfecting procedures. Review of the porvider's current undated Laundry and Linen policy revealed linen from VRE infected residents should have been placed in an appropriate bag before having been placed in a hamper.", "filedate": "2020-09-01"}
{"rowid": 29, "facility_name": "AVERA ROSEBUD COUNTRY CARE CENTER", "facility_id": 435029, "address": "300 PARK STREET   POST OFFICE BOX 408", "city": "GREGORY", "state": "SD", "zip": 57533, "inspection_date": "2020-01-29", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BDC011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control techniques were followed during nursing procedures for: *One of one sampled resident (11) during one of three observed dressing changes performed by two of two registered nurses (RN) (D and E). *Two of two randomly observed nebulizer (neb) cleanings for resident 33 cleaned by two of two RNs (B and F). Findings include: 1. Observation on 1/29/20 at 10:30 a.m. of RNs D and [NAME] during a dressing change for resident 11 revealed RN D: *Applied hand gel then lifted a cloth covering from a wound kit that was placed on a cart outside resident 11's door. *With ungloved hands she: -Opened a plastic bag, removed several unpackaged gauze sponges from the package, and placed them in her opposite ungloved hand. -Reached into the wound kit to remove a packaged dressing, packaged wound barrier wipes, and an unpackaged paper wound measuring tool. -Brought those wound supplies into the resident's room. -Placed them on the resident's bedside table directly on top of a pile of mail without placing a barrier between the wound supplies and the mail. *Washed her hands and put on gloves. With those gloves on she: *Removed the soiled dressing. *Picked up the paper measuring tool and placed it on the wound to measure it. *Cleansed the wound using the gauze pads. *Opened the barrier cream and applied it to the wound area. *Removed her gloves and applied hand gel. She then put on clean gloves and with those gloves she: *Picked up the dressing package from on top of the mail. *Opened the package and applied the dressing to the buttocks. *Removed the gloves and washed her hands. Interview at that time with RNs D and [NAME] regarding the above dressing change confirmed: *Gloves should have been worn to remove unpackaged supplies from the wound kit. *A barrier should have been placed between the clean wound supplies and the mail on the table. *Packaged dressing supplies should have been opened prior to putting on clean gloves to prevent cross-contamination of the clean wound supplies. *RN [NAME] stated her expectation was that gloves were to have been changed between soiled items and clean items. Interview on 1/29/20 at 11:00 a.m. with the director of nursing (DON) C confirmed a barrier should have been used between clean and soiled items, and gloves should have been changed between clean and soiled areas. Review of the provider's (MONTH) 2019 Proper Wound Care Technique policy revealed:*Hands were to have been washed and clean gloves were to have been applied before touching the wound or wound dressings. *Sterile dressings will be used. Nonsterile gloves may be used, but care should be used to avoid touching the surface of the dressing that will contact the wound bed. 2a. Observation on 1/28/20 at 10:00 a.m. of RN B cleaning a neb mask and chamber after a neb treatment for [REDACTED]. *Removed the mask and chamber from the tubing. *Separated the mask from the chamber. *Set the mask in the bottom of the sink as she rinsed out the chamber with water. *Picked up the mask and rinsed it under the water spigot. Surveyor b. Observation on 1/28/20 at 10:35 a.m. of RN F cleaning a neb after completing a treatment for [REDACTED]. *She took the nebulizer to the sink in the room and rinsed the pieces off under the running water. *She turned off the faucet with her bare hands. *She then obtained a paper towel from the dispenser above the sink and used it to dry off the neb device. *She placed the pieces she had rinsed and dried off in a drawer with the neb machine. -She did not change the paper towel that was already in the drawer prior to putting the cleaned pieces on it. He was observed touching and moving items around in his drawer including the paper towel and machine. c. Interview on 1/28/20 at 5:30 p.m. with the director of nursing (DON) confirmed RN F did not follow the appropriate processes for cleaning the neb machine. Surveyor d Interview on 1/29/20 at 11:00 a.m. with DON C confirmed RN B should not have placed the mask in the sink while she rinsed the chamber. Review of the provider's (MONTH) 2014 Concentrator and Nebulizers policy revealed:*Nebulizer components (mask, mouthpiece, and tubing) will be rinsed in clean water and allowed to air dry after each treatment. *Nebulizer masks, cups, and tubing were to have been discarded when discontinued, contaminated, defective, or as deemed by the nurse and after a respiratory infection.", "filedate": "2020-09-01"}
{"rowid": 30, "facility_name": "AVERA ROSEBUD COUNTRY CARE CENTER", "facility_id": 435029, "address": "300 PARK STREET   POST OFFICE BOX 408", "city": "GREGORY", "state": "SD", "zip": 57533, "inspection_date": "2018-12-19", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ZMYV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to review and revise care plans to address residents' current needs for 2 of 12 sampled residents (26 and 37). Findings include: 1. Review of resident 26's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had a history of [REDACTED]. *His 11/14/18 quarterly Minimum Data Set (MDS) assessment Brief Interview of Mental Status (BIMS) cognitive score had been zero indicating severe cognitive impairment. *His current care plan had interventions that included turning and repositioning every two hours. -That included toileting transfers. Observations of resident 26: *On 12/17/18 from 7:45 a.m. through 11:10 a.m. and 2:00 p.m. through 5:30 p.m. revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area. *On 12/17/18 from 3:30 p.m. through 6:30 p.m. in the hallway and dining room revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area during that time. Interview on 12/19/18 at 8:50 a.m. with the director of nurses revealed she agreed: *Resident 26 had not be repositioned and off-loaded from his coccyx area during the above time frames. *The care plans needed to be updated. 2. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 37's 11/26/18 admission MDS assessment revealed: *Her BIMS score had been three indicating severe cognitive impairment. *She was an extensive assistance of one staff member with toileting and personal hygiene needs. -She had been able to indicate toileting needs. -She was always continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *Her 11/26/18 care plan did not have a problem area, goal, or interventions related to her constipation. Interview on 12/19/18 at 11:56 a.m. with the MDS nurse regarding resident 37's care plan revealed: *She had chronic issues with constipation. *There was no explanation why the care plan did not have a problem area related to constipation. Surveyor 3. Review of the provider's effective (MONTH) (YEAR) Care Plan Procedure policy revealed: *It contained details for staff to implement a care plan per Meditech Care Plans. *Each discipline had been responsible for following that policy for care planning in the facility. *The care plan was to have obtained measurable objectives for the highest level of functioning for each resident. *The care plan was to have been structured with a resident centered approach. *Care plans were to have been updated by designated staff.", "filedate": "2020-09-01"}
{"rowid": 31, "facility_name": "AVERA ROSEBUD COUNTRY CARE CENTER", "facility_id": 435029, "address": "300 PARK STREET   POST OFFICE BOX 408", "city": "GREGORY", "state": "SD", "zip": 57533, "inspection_date": "2018-12-19", "deficiency_tag": 690, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ZMYV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (37) had appropriate bowel management. Findings include: 1. Observation on 12/19/18 at 7:05 a.m. of certified nurse aide (CNA) A performing morning care with resident 37 revealed: *She was able to answer yes and no questions related to her daily activities. *She had been able to state no when asked if she needed to have a bowel movement. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. and history of urinary tract infection [MEDICAL CONDITION]. *Her 11/26/18 admission Minimum Data Set (MDS) assessment revealed: -A Brief Interview of Mental Status score had been three indicating severe cognitive impairment. -She --Was an extensive assistance of one staff member with toileting and personal hygiene needs. --Had been able to indicate toileting needs. --Had always been continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *She had not had a bowel movement (BM) for seven days. Interview on 12/19/18 at 7:30 a.m. with CNA A regarding resident 37's toileting habits revealed: *She was able to tell staff when she needed to have a BM. *She preferred to use the toilet and not go in her brief. Interview on 12/19/18 at 9:01 a.m. with CNA B regarding bowel management revealed: *Resident 37 was able to ask to use the toilet. *Every morning in report CNAs were given a list of residents who had not had a BM in three days. -The night nurse printed the report for day shift. *The nurse would inform the CNAs if a resident were to receive a suppository or medication to assist with a BM. -CNAs would be aware of who would need immediate assistance with toileting. *When the resident had results the CNA charted in the computer under Bowel Record. Interview on 12/19/18 at 10:30 a.m. with the director of nursing regarding resident 37 and the bowel management program revealed: *She was unclear why the resident did not flag on the BM report. *There must have been a glitch in the computer system. *They had started keeping the daily BM report to monitor patterns and chronic issues. -Hoped it would prevent a resident from going seven days or more without a BM. *Was unclear what else could be done to prevent the issue from happening again. Interview on 12/19/18 at 11:56 a.m. with the MDS coordinator revealed: *The physician had been contacted regarding resident 37's chronic constipation issue. *The computer system only had one report for no BM in three days. -Had been saving the report. -Unsure of what other measures could have been taken to prevent that from happening again. *When they had a new admission they would run a BM report to make sure the new resident flagged on the report. *Needed to develop a better plan to manage the bowel program. Review of the provider's (MONTH) (YEAR) Bowel and Bladder policy revealed it did not address a bowel management program or system for a resident with constipation.", "filedate": "2020-09-01"}
{"rowid": 32, "facility_name": "AVERA ROSEBUD COUNTRY CARE CENTER", "facility_id": 435029, "address": "300 PARK STREET   POST OFFICE BOX 408", "city": "GREGORY", "state": "SD", "zip": 57533, "inspection_date": "2018-12-19", "deficiency_tag": 758, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ZMYV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure appropriate stop orders and clinical needs were in place for the use of as needed (PRN) [MEDICAL CONDITION] medication for two of five sampled residents (21 and 26) receiving psychoactive medication. Findings include: 1. Review of resident 21's medical record revealed physician's orders [REDACTED].>*[MEDICATION NAME] 100 milligram (mg) by mouth at HS (bedtime) for dementia. *On 11/16/18 via fax for [MEDICATION NAME] 2.5 mg PO (by mouth) q (every) 8 hours prn agitation. *There had not been: -A stop date for the 11/16/18 order. -Documentation by the physician indicating rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Review of the (MONTH) (YEAR) Gradual Dose Reduction-Psychopharmacological Medication form regarding the [MEDICATION NAME] for resident 21 revealed: *Pharmacy recommended a dose decrease. *The physician response indicated no change. -That action required the physician to provide clinical contraindication or exempt condition. -No information had been provided. 2. Review of resident 26's medical record revealed physician's orders [REDACTED]. *Signed and dated on 12/3/18 for [MEDICATION NAME] 0.5 mg p.o. PRN every six hours for agitation. *There had not been: -A stop date for the order of 12/3/18. -Documentation by the physician that had rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Interview on 12/19/18 at 8:50 a.m. with the director of nursing revealed she: *Agreed there was not an effective procedure in place for management of PRN antipsychotic medication orders. *Had educated the physicians on antipsychotic PRN orders but had not kept any documentation of that education. *Had been trying to educate the nurses to enter a fourteen day stop date for all PRN antipsychotic medications ordered. *Agreed the physicians should have been ordering the stop dates for the PRN antipsychotic medications not the nurses. *Agreed the provider had not always been contacted to examine the residents and document the need for continued use of antipsychotic medications. Review of the provider's last reviewed (MONTH) (YEAR) Antipsychotic Medication policy revealed: *Antipsychotic medications will be supervised by the physician for appropriateness of use. *The physician was to have reviewed antipsychotic medications and make recommendations for continuation. *PRN antipsychotic medication orders, and PRN [MEDICAL CONDITION] medication orders, including [MEDICATION NAME], are limited to 14 days. At that time the provider will be contacted to physically examine the resident and document rationale for keeping the PRN order, or, the order will automatically discontinue per date entered in the EMAR (electronic medication administration record).", "filedate": "2020-09-01"}
{"rowid": 33, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2019-03-13", "deficiency_tag": 554, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0JC611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure two of two sampled residents (23 and 27) who self-administered medications had been assessed. Findings include: 1. Observation and interview on 3/11/19 at 3:30 p.m. with resident 23 revealed she had a unit dose [MEDICATION NAME] nebulizer treatment in her hand. She stated the nurse would give her the unit dose before it was due to be taken. She also had a [MEDICATION NAME] hand held inhaler, saline nasal spray, and [MEDICATION NAME] nasal spray on her overbed table. She stated she also self-administered those medications. Review of resident 23's medical record revealed: *She only had an order to self-administer her [MEDICATION NAME]. *The last self-administration assessment had been completed on 3/1/18. Review of resident 23's care plan for self-administration of medications initiated on 5/18/16 revealed: *Focus: I am able to self administer my nebulizer medication. *Goal: I will demonstrate my ability to correctly document and self administer my nebulizers through the next quarter. *Interventions included: I will participate in quarterly self administration assessments to qualify me to continue my self administration privileges. Interview on 3/13/19 at 1:29 p.m. with the Minimum Data Set (MDS) coordinator agreed no assessments had been completed since 3/1/18. The director of nursing and herself had changed the process, so the nurses were assigned that assessment. She stated the timing of the assessments was placed in the treatment administration record (TAR). When she looked on resident 23's (MONTH) and (MONTH) 2019 TARs those assessments did not show up to complete them. She agreed there was only a physician's orders [REDACTED]. 2. Observation on 3/12/19 at 8:04 a.m. of unlicensed assistive personal (UAP) A while she administered medication to resident 27 revealed: *She:-Left two [MEDICATION NAME] 80 milligram (mg) tablets in a plastic medication cup on his table. -Stated He will take them later. We can leave these medications with him. *A clip board on the overbed table with medication administration records (MAR) clipped on it. -UAP A stated the resident was supposed to keep track of when he took the [MEDICATION NAME] tablets on the MAR. -There had been no documentation of the medication times on that MAR. Review of resident 27's last reviewed 3/11/19 care plan revealed he had a [MEDICATION NAME] gel ordered 2/19/19 that he applied himself. There had been no order or assessment for self-administration of that medication. Review of resident 27's 3/16/16 physician's orders [REDACTED]. nursing to check weekly for accuracy. Review of the MDS Coordinator's 10/22/18 progress note revealed resident 27 had continued to self-administer medications. He had been able to review his process with her. There had been no self-administration assessment completed at that time. Review of resident 27's medical record revealed a self-administration for medications assessment had been completed on 1/26/18. There had been no others completed. Interview on 3/13/19 at 3:55 p.m. with the director of nursing (DON) confirmed resident 27 had not been:*Assessed on a regular basis for self-administration of medications. *Documenting on the MAR indicated [REDACTED]. 3. Review of the provider's 9/17/15 Self-Administration of Drugs, Medications and Treatments policy revealed: *Our facility permits residents to self-administer their drugs, medications and treatments unless such practice for the resident is deemed unsafe. *The assessment must be completed and a recommendation from the IDT (interdisciplinary team) to the provider made before the resident may exercise self-administration. *If is was determined the resident can carry out self-administration of medication an order will be obtained. *The resident is responsible for documentation of the medications they are self-administering. *The self-administration right is subject to periodic e-evaluation:minimum of quarterly, and/or an significant change in the resident's ability to self-administer.", "filedate": "2020-09-01"}
{"rowid": 34, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2019-03-13", "deficiency_tag": 657, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0JC611", "inspection_text": "Based on observation, interview, record review, and policy review, the provider failed to review and revise care plans to reflect the current needs of 3 of 13 sampled residents (7, 19, and 31). Findings include: 1. Observations and record review of resident 31 revealed: *On 3/11/19 from 3:30 p.m. through 4:30 p.m. and from 5:00 p.m. through 5:30 p.m. while in her room she: -Sat in her wheel chair beside her bed. -Made no attempts to move herself out of her wheel chair or leave her room. -Was taken to the dining room at 4:30 p.m. -Was taken to her room by an unidentified certified nurse aide (CNA) after her evening meal. --Continued to sit in her chair and made no attempts to move out of her chair or leave her room. *On 3/12/19 from 8:00 a.m. through 11:30 a.m. and again from 2:00 p.m. through 4:30 p.m. she had been in her wheel chair sitting beside her bed or laying in her bed. She made no attempt to self-propel herself, move, or leave her room while in her wheel chair. Review of resident 31's 2/22/19 care plan revealed: *A focus area: elopement risk, revised 10/29/16 that stated: I am an elopement risk/wanderer AEB (as exhibited by) history of attempts to leave facility unattended, impaired safety awareness, failed trial on non-secure unit 10-25 to 10-29-2016. -The provider had not had a secured unit for no less than one year. *For activities of daily living she required limited to extensive assistance for bed mobility, transfers, locomotion, and to use the bathroom. Review of resident 31's weight record revealed a 10% weight loss change from 8/27/18 through 2/19/19. There had not been a focus area or interventions added to the resident's care plan specific to weight loss. 2. Observation and interview on 3/12/19 at 10:35 a.m. of resident 19 during morning care revealed: *CNA A and nurse aide (NA) B transferred her to bed from her wheel chair using the total lift. *They both agreed that they routinely used the total lift on resident 19. Interview on 3/12/19 at 11:15 a.m. with physical therapist C regarding resident 19's locomotion and transfers revealed: *She had recommended staff use the total lift when transferring her. *They had evaluated her recently on 2/19/19. *They were currently working with her on strengthening. Review of the 2/19/19 physical therapy evaluation for resident 19 revealed they had advised nursing staff to use the total lift. Review of the provider's 1/1/19 care plan for resident 19 revealed for: *Locomotion: she needed limited assistance of one person to extensive assistance of two staff to help her propel her wheel chair or to assist her when using her walker. *Transfers: she needed limited assistance. *It did not address the use of the total lift. 3. Observation on 3/13/19 at 8:20 a.m. revealed resident 7 was in the main dining room. She was seated at an assisted eating table. She had consumed the majority of her meal. Observation and interview on 3/13/19 at 10:00 a.m. with resident 7 revealed she was awake and lying crosswise on her bed. She was unable to be understood during our conversation. She had a small spoon and a small paper cup she was eating out of. All of the contents of that cup were gone. She was unable to tell me what she had eaten. Review of resident 7's medical record revealed her weight on: *3/8/19 was 118.5 pounds (lb). *2/8/19 was 123.5 lb. *12/4/18 was 132 lb. *9/14/18 was 136 lb. *A 4.05% weight loss in 30 days. *A 10.61 % weight loss in 90 days. *A 12.87% weight loss in 180 days. Review of resident 7's 11/6/18 care plan revealed: *Focus: I have a potential nutritional problem for weight loss due to dx (diagnosis) of dementia. I have struggled with maintaining my weight in the past with a history of being on Weight Watchers. *Goal: I will maintain adequate nutritional status as evidenced by maintaining weight within 3% of 130 lbs, no s/sx (signs or symptoms) of malnutrition, and consuming of at least 3 meals with Regular diet through the next review date. *Interventions: I need adequate eating time. I often leave the dining room before I get my meal. I am hard of hearing and it is hard for me to converse with my tablemates. I often leave and come back to the dining room forgetting whether I ate or not. -Provide, serve diet as ordered. Currently my diet is Regular. I eat at the Assisted Dining Table to help promote my intake. Monitor intake and record q (every) meal. Review of the registered dietitian's (RD) progress notes revealed interventions that had been started included: *On 11/8/18: Offer a cinnamon roll in late AM to encourage weight gain/maintenance. *On 2/4/19: Resident to move to assisted Dining Table. *There had been no monitoring if the above interventions had been successful. *She continued to have weight loss. Interview on 3/13/19 at 1:30 p.m. with the dietary manager (DM) and RD revealed: *The DM did not monitor residents' weight loss between RD visits. *The nursing department monitored them and would have given a list to the DM to communicate with the RD. *The continued weight loss had not been communicated to the DM or RD. 4. Review of the provider's revised (MONTH) 2006 Care Plans Development - Baseline and Comprehensive policy revealed no information on the revision of care plans.", "filedate": "2020-09-01"}
{"rowid": 35, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2019-03-13", "deficiency_tag": 677, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0JC611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to provide oral care for two of two sampled residents (41 and 204). Findings include: 1. Observation of resident 41 on 3/12/19 from 7:50 a.m. through 8:50 a.m. during personal care revealed certified nursing assistant (CNA) G had not provided any oral care. Interview on 3/12/19 at 10:00 a.m. with resident 41 revealed: *She was unable to use her left arm due to a stroke. *She was able to do some of her own oral care after set-up. *Staff would have helped if she could not complete all of her oral care herself. *CNA G did not assist her to brush her teeth this morning. Interview on 3/13/19 at 10:49 a.m. with resident 41 revealed she had not been assisted with any oral care this morning. Observation on 03/13/19 at 10:50 a.m. of resident 41's toothbrush and basin revealed they were dry. Interview on 3/13/19 at 2:00 p.m. with the director of nursing revealed staff should have assisted resident 41 with her oral care. She stated that had been addressed before and signs had been placed in residents' rooms who required assistance. She agreed resident 41 did have one of those signs. Review of resident 41's 11/6/18 care plan for her activites of daily living revealed: *Focus: I have a history [MEDICAL CONDITION] and my left side is flaccid. I am not able to complete my daily care activities and I need your assistance. *Goal: I will complete my daily care activities by accepting your assistance through my next review date. *Interventions included: -PERSONAL HYGIENE/ORAL CARE: I need limited to extensive assist to perform hygiene activities. I have my own teeth and need you to assist me to clean them. 2. Observations and interviews on: *3/12/19 at 8:15 a.m., 11:00 a.m., 2:00 p.m., and 3:48 p.m. with resident 204 and his wife revealed: -They both stated he had not been assisted with or provided oral hygiene during the above times. -His wife stated: --She knew that, because she had been with him since 7:00 a.m. --She would help him with oral hygiene but had no supplies. --No one had offered supplies or offered to help him. --She preferred the caregivers assist him with oral hygiene. --He had not had oral hygiene provided or offered since he came to the nursing home on 3/6/19. -The resident's: --Lips appeared dry and cracked with a clear, sticky-like coating on them. --Mouth was dry with a build-up of white particles on his tongue and yellow substance on his teeth. *3/13/19 at 11:11 a.m., 1:55 p.m., and 3:00 p.m. with the resident and his wife revealed no oral hygiene had been provided or offered for the resident. -His wife stated again she had no supplies to help him. -She preferred the staff help him. Interview on 3/13/19 at 3:15 p.m. with CNA B revealed she:*Had been the caregiver on resident 204's hallway. *Provided personal care and scheduled baths for all residents on the 200 hall. *Had not provided oral hygiene for him on 3/13/19. *Assisted resident 204 with a bed bath twice a week. -She would only provide oral hygiene on those days. 3. Interview on 3/13/19 at 4:00 p.m. with the director of nurses confirmed oral hygiene was an expectation of activities of daily living. She expected oral hygiene to be done in the a.m. and p.m. with resident care. Agreed oral hygiene supplies should have been provided by the staff. Review of the provider's 1/1/10 Oral Hygiene: Cleaning Dentures policy had no mention of oral hygiene for permanent teeth. No policy had been received by the conclusion of the survey on 3/13/19 at 5:00 p.m.", "filedate": "2020-09-01"}
{"rowid": 36, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2019-03-13", "deficiency_tag": 690, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0JC611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to ensure one of one sampled resident (41) was provided the opportunity to maintain or improve her bladder and bowel continence. Findings include: 1. Observation on 3/12/19 from 7:50 a.m. through 8:55 a.m. of resident 41 during personal care and a full lift transfer revealed: *She had previously received perineal care and her incontinent brief had been changed. *Certified nursing assistant (CNA) G came into the room and checked to see if the resident had been incontinent after approximately one-half hour. *She told CNA G she had not urinated since her brief had been changed. *CNA G had not offered her a chance to use a bedpan, commode, or the bathroom. Review of resident 41's medical record revealed: *She had a urinary catheter from 4/27/18 through 11/1/18 when it was discontinued. *A voiding trial to check post-void residuals was conducted from 11/1/18 through 1/7/19. Review of resident 41's 11/6/18 care plan for her activities of daily living revealed: *Focus: I have a history [MEDICAL CONDITION] and my left side is flaccid. I am not able to complete my daily care activities and I need your assistance. *Goal: I will complete my daily care activities by accepting your assistance through my next review date. *Interventions included: -TOILET USE: I need extensive assist to perform toileting activities. My foley catheter has been removed to see if I can tolerate/urinate w/o (without) it. I am sometimes incontinent. I need you to perform bladder scans post void until it can be determined that I am adequately voiding. I am continent of bowel. -TRANSFERS: I am dependent upon staff to transfer me using a Hoyer lift. Review of resident 41's Minimum Data Set (MDS) quarterly reviews completed on the following revealed: *11/1/18: Required extensive assistance of one staff for transfers and toilet use. -She had a urinary catheter and was continent of bowel. *2/1/19: Required extensive assistance of two staff for transfers and toilet use. -She did not have a urinary catheter and was frequently incontinent of bladder and bowel. Interview on 3/12/19 at 8:53 a.m. with CNA G revealed resident 41 was not able to use the toilet or commode due to her using a full lift. She stated she previously used the toilet when she had been transferred with the standing lift. Interview on 3/13/19 at 10:40 a.m. with CNA I stated resident 41 did not use the commode or the toilet. She would have been able to transfer her with a toileting lift sling if there was one available. She stated she was not sure if the resident would have been able to maintain her balance when sitting on the commode. Interview on 3/13/19 at 1:30 p.m. with the MDS coordinator revealed no bowel and bladder assessments were completed to determine if a resident would have been appropriate for a bowel and/or bladder training program. Interview on 3/13/19 at 2:00 p.m. with the director of nursing revealed resident 41 had not been: *Assessed for a toileting program. *Given the opportunity to have remained continent when her transfer method had been changed.", "filedate": "2020-09-01"}
{"rowid": 37, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2019-03-13", "deficiency_tag": 880, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0JC611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure proper handwashing, glove use, wound care, and personal protective equipment procedures, and mechanical lift sling maintenance had been followed: *For one of one observed certified nursing assistant (CNA) (G) during personal care for resident 41. *For one of one observed resident (19) on contact precautions. -Designed for residents known or suspected to be infected with microorganisms that could have been transmitted by direct contact with the resident or environment. *For three of three observed registered nurses (RN) (D, E, and H) during topical medication administration and dressing changes for three of three observed residents (9, 19, and 40). Findings include: 1. Interview on 3/11/19 at 5:44 p.m. with RN H regarding resident 9 and what precautions were required revealed: *She stated precautions were only required if doing direct resident care. *Resident 9 had a history of [REDACTED]. *Gloves and gowns were all that would be required during wound care. 2. Observation on 3/12/19 from 7:55 a.m. through 8:55 a.m. of CNA G during personal care for resident 41 revealed: *CNA G entered the room and with no hand hygiene she: -Put on the resident's support hose. -Checked to see if her incontinent brief needed to be changed. -She then went and put on gloves then checked the incontinent brief again. -Removed those gloves and did no hand hygiene during the entire observation. *Resident 41 was transferred from the bed to her wheelchair with a total lift. -The sling used had come from a storage bag on the lift and was put back in that storage bag after the transfer. *Interview with CNA G at 8:40 a.m. revealed there was a shortage of slings, so they were used by multiple residents each day. 3. Observation on 3/12/19 from 8:20 a.m. through 8:30 a.m. of RN H during topical medication administration revealed: *RN H entered the resident's room with three small plastic medication cups. -Those cups each contained a different topical medication. -She set them on the bedside dresser. *She did not perform hand hygiene before putting on gloves. *She went into the bathroom, wet a paper towel, and washed around the resident's mouth. -She applied [MEDICATION NAME] to red areas on the resident's face. *Without changing gloves she pulled the blanket down and pulled the resident's pant legs up. -Removed the left heel boot and applied [MEDICATION NAME] lotion to both legs and feet. -Pulled both pant legs down and reapplied the left heel boot. *Took her gloves off and with no hand hygiene she went out of the room to the treatment cart. 4. Continued observation from 8:30 a.m. through 8:35 a.m. revealed RN H: *Returned one plastic medication cup of a topical medication to the medication cart. *Resident 40 was at the treatment cart, and RN H did the treatment on her right little finger. *She put on gloves, opened a drawer, and: -Retrieved a bottle of wound cleanser and two 4 by (X) 4 gauze sponges. -Cleansed the resident's right little finger. -Did not change her gloves, retrieved a Band-Aid and a small packet of [MEDICATION NAME] from the treatment cart. -Placed some [MEDICATION NAME] on the Band-Aid and applied it to resident 40's finger. *Took her gloves off and did not perform any hand hygiene. 5. Observation on 3/12/19 from 2:00 p.m. through 2:30 p.m. of RN H during a wound care treatment for [REDACTED]. *She gathered supplies of an ABD and 4 by (X) 4 gauze out of the treatment cart. *Used hand sanitizer, put on gloves, and opened the door to the resident's room. *Assisted the bath aide with transferring the resident from the bath chair to the bed. She pushed the bath chair out of the way. *With those same gloves on she connected the two ends of the wound vac tubing. *Removed her gloves and washed her hands. *Put the dressing supplies on the bed with no barrier under them. *Put new gloves on, removed the soiled dressing from the right ischial wound, and with those same gloved hands: -Cleansed the wound with sterile water. -Removed her gloves and with no hand hygiene put on a new pair of gloves from where CNA G had placed them on the sheet. -Took the dressing supplies from where she had placed them and put a new dressing on. -Removed her gloves and did not perform any hand hygiene before leaving the room. *She then stated Oh, I should have had a gown on. *She stated she was not sure where the gowns were located. 6. Review of resident 19's complete medical record revealed: *She was positive [MEDICAL CONDITION] in her wounds. *She was on contact isolation. -Staff were to glove and gown when providing care. Observation on 3/12/19 at 9:07 a.m. with RN D in resident 19's room revealed: *After transferring the resident into his wheelchair his sling was put into the pouch on the back of the total lift. *The lift was then taken across the hall to another resident's room. Interview on 3/12/19 at 2:12 p.m. with RN D concerning care as mentioned above revealed: *She had put the sling in the pouch on the lift, and it had been taken to another resident's room. *The lift was not wiped off with sanitizer wipes. -She agreed that sling should not have left the room, and the lift should have been sanitized. *She was aware resident 19 was on contact isolation. Observation on 3/13/19 at 2:38 p.m. with RN [NAME] during dressing changes for resident 19 revealed: *She had gloves on but no gown. *That resident did not have a Duoderm to her buttocks so she applied one to her opened area on her buttock. *She took off a Duoderm on her left hip and applied a new Duoderm to that area. *She took off the dressing to the lower extremities. -She changed dressings to the ankle areas on both legs with [MEDICATION NAME] Gentle AG+. *She had used a scissors to cut the dressings. *No handwashing or glove changes were done during the above dressing changes. *She took off her gloves before leaving the room. *She put the scissors in the top drawer of the treatment cart without it wiping off. Interview on 3/13/19 at 3:45 p.m. with the director of nursing (DON) concerning resident 19's above care revealed: *Her sling should have not been taken out of her room. *Handwashing and glove changes should have been done between each dressing change. -The resident had several areas with dressings. *The lift should have been completely wiped off with disinfectant when taken out of the resident's room. *Gowns and gloves should have been worn when entering the contact isolation room. 7. Review of the provider's (MONTH) 2004 Handwashing policy revealed to hand wash before and after contact with body fluids. Review of the provider's (MONTH) 2003 Dressing Change policy revealed: *Wash hands thoroughly. -Use standard precautions as necessary to shield you and your clothes from wound drainage. *Put on non-sterile examination (exam) gloves. *Remove dressing and discard in plastic bag. *Remove exam gloves, discard in plastic bag. *Wash hands thoroughly. *Put on non-sterile exam gloves. *Perform dressing change. *Document dressing change. Review of the provider's (MONTH) (YEAR) Personal Protective Equipment policy revealed: *Handwashing was to be preformed: -Before touching a resident. -Before clean procedures. -After resident body fluid exposure risk. -After touching resident's surroundings (faucet, cupboards, drawers, closet) -Before putting on gloves, mask, or gowns. -After removing gloves, mask, or gowns. *Gowns should have been worn for all persons entering rooms of residents who were on contact isolation. Review of the provider's undated Isolation Precautions policy revealed: *Contact precautions included: -Wear gloves and gown when entering the room. -Change gloves after having contact with infectious material and between soiled to clean tasks. -Clean and disinfect all commonly used equipment prior to the use for another resident.", "filedate": "2020-09-01"}
{"rowid": 38, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 550, "scope_severity": "J", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, policy review, and admission packet review, the provider failed to ensure one of one sampled resident's (49) personal space and privacy was protected from one of one sampled resident (17) who had a history of [REDACTED]. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment.*For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center.*For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed necessary (Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting process), including feedback from the Medical Director. *For staff education: -Immediate education will be completed with all staff prior to their next shift, which will include the review of the following policies: Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting Process. We will focus on identifying signs and symptoms of abuse, how to report, when to report and who to report to in order to address the potential for a similar situation in the future. Staff will be knowledgeable about protecting themselves and other residents in accordance with our policies. Education completion will be reported to the Administrator. *For Medical Director education: -The review of the admission process and following policies will occur with the Medical Director upon his return the week of 3/19: Abuse and Neglect; Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident abuse; Preventing Resident Abuse, Resident Rights; Resident Incidence/Variance Reporting process. On 03/27/18 at 11:45 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 17's 3/8/18 required Healthcare Facility Event Reporting form revealed: *Date and time of event: 3/8/18 0800 (8:00 a.m.). *Type of event being reported: Suspicion/allegation of abuse/neglect. *Allegation type: Other: Resident to resident physical contact. *Suspicion/Allegation of Abuse/Neglect: -Resident to resident/Patient to patient. -Both names and cognition: Resident in the morning grabbed a female residents butt which cause (ed) her to fear him. *Provide a brief explanation of event being reported. Please include names (s) of Patient/Resident/Personnel/Family/Visitors involved with event: -Residents morning nurse walked into residents room to give morning meds and said good morning, resident than proceeded to grab the female nurse by the neck and tried to lick/kiss. His nurse backed away while removing his hands from her neck asking patient (resident) to please take respiratory meds. Resident than proceeded with his inhaler stating is not like your ta-tas there's milk than grabbed the nurses breast. His nurse explained this was very inappropriate and not acceptable to touch people, resident stated that's all you woman are good for and resident than tried to grab his nurse by the neck a second time, nurse proceeded to leave the room. Resident came out into hallway and smacked a staff members butt following a resident. The female resident he hit on her butt was very upset and fearful of resident. SS (social service) was asked to assist in alleviating his behavior, resident began to swing his cane at the female staff, the DON (director of nursing) was notified to assist in the situation in which resident after about 10 minutes was redirected into the office in which his primary physician was in the office, his physician attempted to redirect resident without success, resident was assisted to his room in which when male nurse attempted to give injection ordered, he became combative and injured a staff, resident attempted to get out of the facility when the DON was attempting to redirect, he did get the door open and staff successful after a few minutes in redirecting. Physician did assist with medication administration in a enclosed room after resident injured DON attempting to redirect him. Resident has had a history of [REDACTED]. MD (medical doctor) has adjusted his medication in an attempt to assist with decreasing his behaviors. His latest BIMS (Brief Interview for Mental Status) was completed in (MONTH) of (YEAR) and was documented as 12. Resident when discussing his behavior states 'I'm just crazy.' This afternoon resident is pleasant and ambulating around the facility no further behaviors noted this afternoon. *Investigation conclusion: -Conclusionary summary statement of facility investigation: It is questionable if having a roommate is escalating his behaviors as (resident 17's name) makes many comments about his roommate and status. DON and staff working on moving roommate to determine if this will assist in decreasing his agitation and outbursts with sexual behaviors. Every shift documentation monitoring an increase or decrease in behaviors to be completed due to increase in medication dose. *Substantiation and Action: -Was abuse/neglect allegation substantiated? Yes. -Why or Why not? Resident to resident sexual groping. *Was it a willful act? Yes. *Action taken by the facility: Personnel education and other were checked. *Other, please specify: Physician present at the time, new orders in medication, change in room mate. *No documentation to support: -Who the female resident was that he had physical contact with. -The cognition level of the female resident who was involved in that event. -Follow-up interviews with the staff members who had been involved or witnessed the event. -That an investigation and interview had been conducted with the resident or staff members who were touched by him in an inappropriate manner. 2. Interview on 3/13/18 at 2:26 p.m. with resident 49 revealed: *She had been: -The other resident mentioned in the 3/8/18 event with resident 17. -Coming out of the dining room after finishing her breakfast. -Watching for residents coming in and going out for safety purposes as it was crowded. -Coming out and resident 17 was going in to the dining room. *She stated: -He reached behind me and grabbed my left butt and squeezed a handful of it. -One of the male certified nursing assistants (CNA) (stated CNAs name) asked if I was alright. -I told him what happened and he said that wasn't right and would report it. -I went to my room for about thirty minutes to pull myself together and then went down to (name of SSD) office and she was aware of it. -I was told he was taken out of the dining room and that he had hit the table hard with his cane. *He had not attempted to approach her before that day. *She stated I heard he has had hands on with other residents. *In the past she had tried not to come in contact with him. *She stated: -I felt very violated that day when he grabbed my butt. -It was a violation of my privacy especially at this age. -I shouldn't have to fear for that type of behavior from an old man in a place like this. -It was an invasion of my rights. -I haven't seen him or heard him be inappropriate with the others but I do hear the staff tell him hey stop that. -I have heard he can be grabby and at this age would never think of stuff like this, thinking and worrying of old people doing stuff like that. *She: -Had not been injured when he grabbed her buttock. -Stated It was very unsettling and I was embarrassed. I could feel my face turning red. Review of resident 49's medical record revealed: *A BIMS score of fifteen meaning she was alert and oriented to time, person, and place. *On 3/13/18 at 9:59 a.m. the social service coordinator (SSC) S had documented: -Late entry for 3/8(18). -(Resident's name) approached SS and stated that another resident was walking out of dining room and grabbed her bottom. -She was distressed. -SS calmed her down and apologized that she had to endure that. -SS assured her that our DON would file a state report, and that we would assure that this resident did not do that to her again. *The documentation by the SSC S on 3/13/18 had: -Occurred five days after the 3/8/18 event. -Been the only documentation and interview by administration regarding the 3/8/18 event involving resident 17. 3. Observation and interview on 3/13/18 at 3:36 p.m. with resident 17 revealed he: *Had been sitting in his room watching television. *Was alert and pleasant to visit with. *Had remembered the event that occurred on 3/8/17. *Stated: -The other day the night nurse came in with meds, we got mad at each other and I'm not sure why. -She left and I went out to the dining room to eat. -The staff came and got me and gave me this shot, I thought I was dying but then I woke up. -The doctor was here and he helped them. -There was a lot of staff and they were grabbing me and my hands I have no idea why but there was a lot of them. -I get angry sometimes and not sure why. -I blackout and do things and can't remember them. *Several times he stated I have times where I black out and I can't remember the things I do. Review of resident 17's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had a BIMS score of twelve meaning he had moderate cognitive impairment. *He was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had: -The capability of wandering throughout the facility with a history of going into other residents' rooms. -A history of touching other female residents and staff members inappropriately and in an undignified manner. *The physician had assessed the resident every sixty days and as needed (prn) for any acute health care concerns identified by the staff. *The documentation from those physician's visits identified: -On 9/28/17: Follow up on chronic management of issues related to [MEDICAL CONDITION] associated with dementia and depression. He refers to himself as crazy. He says sometimes he voices or does crazy things. We have tried to taper quetiapine ([MEDICATION NAME]) and has had breakthrough symptoms that have really been distressing to other residents and staff and even to him. He is aware of the hallucinations and inappropriate behaviors. -On 11/9/17: In general terms we follow him for dementia and some associated behavioral issues with delusions and [MEDICAL CONDITION]. *He had been taking [MEDICATION NAME] 50 milligrams (mg) twice a day for [MEDICAL CONDITION] since 2/28/17. -A gradual dose reduction had been contraindicated d/t (due to) an increase in his behaviors would have occurred. *On 3/6/18 the physician had increased his bedtime dose of [MEDICATION NAME] to 75 mg d/t bizarre behaviors including some sexual references in front of the nurses. -Plan: We could make a small increase in quetiapine ([MEDICATION NAME]) dosage in the evening to try to help sleep better and see if this also helps him to control some of his impulsive behaviors sexual expressions. Review of resident 17's nursing progress notes from 5/4/17 through 3/14/18 revealed: *On 5/14/17 at 12:26 p.m.: Resident assigned seating in dining area moved to table with peer secondary to inappropriate touching of female peer. Staff will continue to monitor. *On 7/11/17 at 8:30 a.m.: The charge nurse documented: CNA reported that resident was in dining room after breakfast and touched her inappropriately on chest and twice on the hip; CNA reported this to me and will document in behavior log as well. *On 8/29/17 at 8:18 a.m.: CNA noted that resident was in the DR (dining room) attempting to kiss another female resident but she was vehemently stating 'no' to him. Intervened and stated to resident that that behavior is inappropriate and that female resident is stating no. This resident made a inappropriate facial gesture and said that 'I will get you next time.' I spoke to resident about the incident. Reinforced to him that he must not touch other residents. He states understanding at this time. *On 8/29/17 at 1:09 p.m. by the SSC S: It was reported to SS that (resident 17's name) kissed a female resident on the cheek and put his arm around another female resident who told him to stop; (he did comply). SS talked with (resident 17's name) explaining that he could not touch any resident without their permission. He stated he understood and would stop. -No documentation to support the physician and family had been notified. *On 9/7/17: -At 9:21 a.m.: The activity staff had requested the charge nurses assistance. The resident and another female peer were arguing over an exercise stick. The other resident had taken the exercise stick from him. The charge nurse assisted the resident to another area. The activity staff reported to the charge nurse This resident had also grabbed her (charge nurse) in an inappropriate body part as she was attempting to separate the residents. Staff was able to redirect him to sit in a different area, although resident did attempt to move back to female resident's chair, and then moved back to his chair. -At 9:55 a.m.: Staff reported that this resident again attempted to move back over to the female resident that he had altercation with. This resident then left the lobby and I spoke with him about the behaviors he was involved in. He indicated that 'it just starts.' I reinforced to him that he needs to not let it start. *On 9/11/17 at 4:06 p.m. by the dietary director: It has been brought to my attention that (resident's name) slapped one of my staff on her bottom. It happened on Wednesday the 6(th) of September. This morning at breakfast when taking his order he hand signaled groping her chest. *On 2/9/18 at 11:48 a.m. Resident tried to swat CNA on rear end, CNA dodged, and resident tried to strike CNA with fist. *On 3/8/18 refer to the above online reporting form. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse/neglect. -The physician and family had been notified after each above event. -The inappropriate sexual behaviors exhibited above by the resident had been reviewed in full to ensure the mental health, personal privacy, residents rights, and dignity was maintained for all who had been involved in those altercations. Review of resident 17's current and revised care 1/15/18 plan revealed: *There was documentation to support his [DIAGNOSES REDACTED]. *The staff were to have redirected the resident when he: -Had inappropriate sexual behaviors or comments. -Attempted to touch other residents without their consent. -Wandered into other residents' rooms. *It confirmed he had episodes of inappropriate behaviors where he would say sexually inappropriate things and attempt to touch them. *The staff were to have monitored and recorded occurrences of behavioral symptoms and document per provider's policy. Interview on 3/13/18 at 9:38 a.m. with CNA F regarding resident 17 revealed: *She confirmed he had a history of [REDACTED]. *she stated: -He will attempt to do things to us CNAs that is embarrassing and inappropriate. -He slaps us on the butt. -He told me once I needed to take my pants down and do things for the other residents mostly his roommate. -The kiosk is by his room and sometimes when I am charting he will come out and grab at my chest or butt. *She had: -Requested not to work with him and would not walk into his room by herself. -Witnessed him attempting to kiss resident 36 on the forehead, hugging her, and sat by her today. *Resident 36: -Appeared to not have been bothered by his actions. -Had episodes of confusion. *The medication aide had reminded him his actions were inappropriate, and he moved to another spot. *She had been informed by administration they were reviewing his medications. Review of resident 36's medical record revealed she had a BIMS score of six. -That score indicated she had severe cognitive impairment. Interview on 3/14/18 at 9:16 a.m. with CNA O regarding resident 17 revealed he: *Was aware of the resident's inappropriate touching other female residents and staff. *Stated: -I'm male so he's not like that with me. -Last week he was very aggressive when he grabbed (resident 49's name) bottom. -She was very upset about it. *Had reported the incident to licensed practical nurse (LPN) [NAME] *Agreed it was: -A violation of her private and personal space. -Her right to be free from that type of behavior. Interview on 3/14/18 at 11:57 a.m. with LPN A regarding resident 17 revealed she: *Had been the nurse involved with the event that took place on 3/8/18. *She stated: -After that he tried to grab me a second time around the neck, and so I just left his room. -The bathaide came up and said he smacked her on the butt and (staff name) (CNA O) told me he grabbed another resident inappropriately by then he was in the dining room. -I went and got (staff name) (SSC S) and when we tried to approach him that his behaviors were inappropriate he got mad, started slamming his cane on the table, and screaming. -I went and got the DON to help and she wanted me to not be around him d/t being pregnant and his behaviors. -You just never know what to expect from him and it makes you uncomfortable and fearful. -He tends to single out females especially the bathaide and this one lady from another wing. I don't work down there so I'm not sure who she is but I can tell she is confused. She repeats the same questions a lot. -He's grabbed and touched me before and I don't like it, makes me uneasy. -We have been told to redirect him which we do. Sometimes it works and sometimes it doesn't. *Had not been exhibiting any behaviors after the shot he received on 3/8/18 of [MEDICATION NAME] until today. -She stated He's starting to approach female residents again. *Had confirmed: -His behaviors had been sporadic and with no consistent pattern. -The female residents and staff should not feel and fear from that type of violation. *Stated If I would have done that it would have been considered an assault. But since we are staff its not really looked at as a huge concern. Interview on 3/14/18 at 12:40 p.m. with CNA P regarding resident 17 revealed: *She: -Was the bathaide for the 100 and 300 wings. -Had been responsible for assisting him with his bath. *The resident was verbally, sexually, and physically inappropriate with her during those times. -At times he would have slapped her on the bottom. *She stated: -Recently he slapped me on the butt so hard that it hurt, and he just laughs about it. -He will tell you: --That is what womans are good for. --Womans are here to be sexual pleasing and we are not worth more than that. -It makes me feel very disrespected. -I know they have talked to him about his behaviors towards us and the residents, but I just don't think its been hard enough. -We are always told by the administration and (staff name) (SSC S) that they will take care of it. *She: -Was aware of the altercation he had with resident 49 and the staff on 3/8/18. -Stated (Resident 49) was very mad and upset. She stayed in her room the entire day. -Had reported all behavioral concerns involving the resident to her charge nurse. Interview on 3/14/18 at 8:30 a.m. with the medical director regarding resident 17 revealed he: *Was aware of the resident's inappropriate verbal, physical, sexual, and aggressive behaviors towards other residents and staff. *Was in the facility on 3/8/18 when the resident had exhibited uncontrollable and inappropriate behaviors. *Agreed the resident's type of behaviors that day would have been considered inappropriate and violent in nature. *Did not send the resident to the emergency room (ER) for treatment or evaluation since he was already in the facility during that time. *Assisted the staff with the administration of [MEDICATION NAME] by injection to the resident. *Was not aware of all types of behaviors the resident had exhibited. *Confirmed most of the resident's behaviors were sexual in nature. *Considered trying Depovera to try to control those behaviors but had not initiated it yet. *Confirmed: -The resident was taking [MEDICATION NAME] for his behaviors and had failed attempts of a gradual dose reduction (GDR) in the past. -The [MEDICATION NAME] was recently increased d/t inappropriate and sexual behaviors towards residents and staff. *Was not sure what triggered the resident's behaviors. *Stated: -His behaviors are just random. -I know his current roommate is failing which upsets him and has caused him to not sleep well. -He has a long history of [MEDICAL CONDITION], and we try to manage most behaviors with redirection and medications. -He clearly misbehaves and I can't say if this is appropriate placement for him or not. -We really don't have the resources and support for psych services in this area. -No we don't have psych support or resources to utilize. -He already has a long history of [MEDICAL CONDITION], so I really don't see the need for an inpatient evaluation. *Had been concerned about the other residents and staff safety but unsure what to do for it. *Agreed the resident would likely exhibit those types of behaviors again. Interview on 3/14/18 at 3:05 p.m. with the administrator, DON, Minimum Data Set (MDS) assessment coordinator, and social service coordinator (SSC) S regarding resident 17 revealed: *They confirmed: -He had [MEDICAL CONDITION] with a history of sporadic and verbal, physical, and sexually inappropriate behaviors. -His behaviors: --At times were a problem and had been discussed during stand-up meetings. --Were reviewed as needed (prn) by the interdisciplinary department team (IDT). --Had no specific pattern and recently had been more directed at females. --On 3/8/18 were the worse they had ever been. *Initially they thought his behaviors had been triggered from his roommate and related to baths. *The DON: -Stated He mostly has sexual comments. -Was not aware of any events involving other residents until recently. -Would have expected the staff to notify her when residents had uncontrollable behaviors. *The SSC S confirmed: -The resident had sexually inappropriate behaviors, and the most recent incident was the worst. -She had spoken with resident 49 immediately after the incident on 3/8/18 and again later that day. -She had not documented those discussions with resident 49 and should have. *They: -Had not been aware resident 49 stayed in her room that day. -Agreed since it was a traumatic event for resident 49, and there should have been follow-up with her. -Were unaware of any physical, verbal, and sexually and inappropriate behaviors towards staff prior to the incident with LPN [NAME] -Would not have allowed the staff to determine whether they wanted to work with a certain resident or not. -Would have tried to rearrange the staff assignments to accommodate those requests. -Had been aware he had stated he did not remember when those episodes occurred and what had happened. -Was unsure if he actually remembered them or not. -Confirmed all the staff were required to: --Complete the abuse mandatory training. --Report any events or behaviors where there was the potential for abuse to the supervisor or administrative staff. -Had a difficult time transferring residents with behaviors to other facilities. -Used to transfer residents with behaviors to the ER for evaluation and admission but now they could not. --There was no further comment as to why not. -Could have contacted the primary physician and had him sent to the ER if needed. *There was one psychiatrist the medical director used if needed, but those appointments would have been a couple of months out. *The medical director reviewed and ordered most of the medications for his residents who had behaviors. *They had: -Been working with the physicians to support referrals to a behavioral service located in the area for them to utilize. --That process had been taking a long time due to (d/t) the lack of understanding from the physicians and their support to utilize them as a resource. -Access to two psychologists for support and one would have been able to come directly to the facility. --Those services required a referral from the resident's primary physician. -Been aware of the need for those behavioral services in the facility. *There had been recent education provided for the staff on professionalism and how to handle resident 17 and his behaviors after the event on 3/8/18. -There was no documentation to support that education for the staff. -The DON stated: --The education was all verbal, and I talked only with the staff working that day. --They were told to tell the others. *The administrator: -Indicated they had not been aware of all the incidents that the surveyors mentioned and reviewed above. -Would have expected the staff and residents to have told them about those incidents. -Stated We would have responded to those incidents had we known it was occurring that frequently. *They had been concerned about the staff and resident interviews above and having no knowledge of all those issues and concerns. *No further comment was provided to support: -If resident 49 and other residents should have been interviewed after the incident on 3/8/18. -If those staff members involved in the 3/8/18 incident should have been interviewed as part of the investigation. Interview on 3/15/18 at 10:23 a.m. with the administrator regarding resident 17 revealed: *He stated: -I feel like (resident 17's name) is being villanized by (resident 49's name) and getting other residents to say he is out of control. -He did not know how they could have been at fault if they had not known all the concerns of those residents and were not aware of those certain instances. -I feel most things are staff driven with his behaviors and not directed towards other residents. *After further review of the resident's sexual behaviors involving cognitively impaired residents and their inability to give verbal consent he stated We should have involved behavioral services for (resident 17's name). Observation of resident 17 on 3/15/18 at 12:15 p.m. in the copy room revealed: *The surveyor had been waiting to use the printer. *The resident arrived in the room and stated They think I'm crazy and pointed to her chest. *The surveyor: -Looked down and the resident swiped his finger up towards her nose. -Thought he had been joking with her. *He had attempted to grab her copies and appeared to be agitated. *The surveyor: -Turned around towards the printer, and the resident grabbed her bottom. -Stated Oh we better not do that. *The resident: -Smirked at the surveyor. -Had been on one-to-one observation by the activity coordinator and LPN A at that time. -*They had asked him to go back with them after he grabbed the surveyor's bottom. -He walked quickly through the copy room, out the other side door, and away from them. *LPN A stated This is his normal behavior and he's riling up again. Review of the provider's 1992 Briggs Healthcare pamphlet in the admission folder regarding resident rights revealed: *As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights. *Exercise of rights: You have the right and freedom to exercise your rights as a resident of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion, or reprisal. *Resident Behavior and Facility Practices: -Abuse You have the right to be free from verbal, sexual, physical or mental abuse. -Staff treatment: --The facility must implement procedures that protect you from abuse, neglect or mistreatment. --In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. --All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. *Quality of life The facility must care for you in a manner and environment that enhances or promotes your quality of life. Review of the provider's undated Welcome to Regional Senior Care pamphlet in the admission folder revealed: *Home: It is a home, a place where people live. Privacy is to be respected. Review of the provider's undated Resident Responsibilities paper in the admission folder revealed: *As a resident of the (facility name), you have many rights. Your help is appreciated in making sure the facility runs smoothly and meets your needs as well as those of your neighbors. The following are some guidelines for residents to follow to ensure a pleasant stay (facility name). -Be kind, considerate and respectful of your roommate, other residents, and staff.", "filedate": "2020-09-01"}
{"rowid": 39, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 600, "scope_severity": "J", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure all residents and staff were free from the verbal, physical, and sexually abusive behaviors from one of one sampled resident (17). NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment. *For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center. *For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed necessary (Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting process), including feedback from the Medical Director. *For staff education: -Immediate education will be completed with all staff prior to their next shift, which will include the review of the following policies: Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting Process. We will focus on identifying signs and symptoms of abuse, how to report, when to report and who to report to in order to address the potential for a similar situation in the future. Staff will be knowledgeable about protecting themselves and other residents in accordance with our policies. Education completion will be reported to the Administrator. *For Medical Director education: -The review of the admission process and following policies will occur with the Medical Director upon his return the week of 3/19: Abuse and Neglect; Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident abuse; Preventing Resident Abuse, Resident Rights; Resident Incidence/Variance Reporting process. On 03/27/18 at 11:45 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 17's 12/6/17 Required Healthcare Facility Event Reporting form revealed: *The report and investigation had been completed by the director of nursing (DON). *Type of event being reported: Suspicion/allegation of abuse/neglect. *Allegation type: Other: Resident slapped another resident. *Suspicion/Allegation of Abuse/Neglect: -Resident to resident/Patient to patient. -Both Names and Cognition: Resident 17 and 26 had been typed in that area. No documentation to support their level of cognition. *Is the individual capable of providing an explanation of the event or capable of participating in investigation? The word no had been typed in that area. *Provide a brief explanation of event being reported. Please include names (s) of Patient/Resident/Personnel/Family/Visitors involved with event: -At approximately 8 am (a.m.) this morning, this resident (17) was walking out of the dining room, as CNA (certified nursing assistant) F was assisting resident (26) in a w/c (wheelchair) in to the dining room. As this resident passed the resident in the w/c, reached out and slapped him on the right forehead. When the CNA told him he cannot hit other residents, he then reached out and slapped the CNA in the right arm. He then put his fists up as if it (to) punch her, but CNA stated he was smiling the whole time and then he walked away. There were no red marks or any other apparent injury to the resident (26). *Law Enforcement and the social services department had not been notified, because there was no injury. *Investigation conclusion: -Throughout the investigation process and interview process, (resident 17's name) stated he did not do this as an aggressive act, he demonstrated to this writer that he tapped the other resident on the forehead in a manner and stated good morning, (resident 17's name) did tap this writer on the forehead very softly on three occasions and his comment each time was that he was getting his attention with stating good morning. (Resident 17's name) latest BIMS (Brief Interview for Mental Status) is noted as 12 completed in October. In review of documentation, no other physical behaviors have been noted in regards to other residents. Staff to monitor for any agitation or further incidences. Other resident involved unable to give his version of what occurred. This writer explained how his actions could have been perceived by others. *Was abuse/neglect allegation substantiated: -No. -Why or why not? Resident did not do out of aggression. *No documentation to support: -There had been the potential for abuse as demonstrated by the resident's behavior towards another resident. -An incident report, investigation, and interview had been completed on the resident he had touched in an inappropriate manner. Review of resident 26's medical record revealed: *A BIMS score of 9. *That score indicated he had: -Mild cognitive impairment. *The potential to have been interviewed on the above incident with resident 17. Review of resident 17's 3/6/18 Behavior Incident Report form revealed: *At 12:23 p.m. licensed practical nurse (LPN) A had approached the resident and asked him to provide a urine sample. *Incident Description: Resident was asked to give a urine sample. Resident then responded with you hold the cup and I'll pull my big peter out. Resident was educated that this kinda (kind of) talk was not appropriate. He than responded with you ask my bathaide how big he is she was rubbing and pulling, do you want to see? Resident reminded again not appropriate to talk to other(s) this way and told to let a nurse know when he needs to urinate. Resident responded with fine I'll say it in (another language) maybe you will understand. *Mental status: Oriented to person, situation, place, and time. *The DON had reviewed the incident with no further action taken. Review of resident 17's 3/8/18 Required Healthcare Facility Event Reporting form revealed: *The report and investigation had been completed by the DON. *Date and time of event: 3/8/18 at 8:00 a.m. *Type of event being reported: Suspicion/allegation of abuse/neglect. *Allegation type: Other: Resident to resident physical contact. *Suspicion/Allegation of Abuse/Neglect: -Resident to resident/Patient to patient. -Both names and cognition: Resident in the morning grabbed a female residents butt which cause (ed) her to fear him. *Provide a brief explanation of event being reported. Please include names (s) of Patient/Resident/Personnel/Family/Visitors involved with event: -Residents morning nurse walked into residents room to give morning meds and said good morning, resident than proceeded to grab the female nurse by the neck and tried to lick/kiss. His nurse backed away while removing his hands from her neck asking patient (resident) to please take respiratory meds. Resident than proceeded with his inhaler stating is not like your ta-tas there's milk than grabbed the nurses breast. His nurse explained this was very inappropriate and not acceptable to touch people, resident stated that's all you woman are good for and resident than tried to grab his nurse by the neck a second time, nurse proceeded to leave the room. Resident came out into hallway and smacked a staff members butt following a resident. The female resident he hit on her butt was very upset and fearful of resident. SS (social service) was asked to assist in alleviating his behavior, resident began to swing his cane at the female staff, the DON (director of nursing) was notified to assist in the situation in which resident after about 10 minutes was redirected into the office in which his primary physician was in the office, his physician attempted to redirect resident without success, resident was assisted to his room in which when male nurse attempted to give injection ordered, he became combative and injured a staff, resident attempted to get out of the facility when the DON was attempting to redirect, he did get the door open and staff successful after a few minutes in redirecting. Physician did assist with medication administration in a enclosed room after resident injured DON attempting to redirect him. Resident has had a history of [REDACTED]. MD (medical doctor) has adjusted his medication in an attempt to assist with decreasing his behaviors. His latest BIMS (Brief Interview for Mental Status) was completed in (MONTH) of 18 and documented as 12. Resident when discussing his behavior states 'I'm just crazy.' This afternoon resident is pleasant and ambulating around the facility no further behaviors noted this afternoon. *Investigation conclusion: *Conclusionary summary statement of facility investigation: It is questionable if having a roommate is escalating his behaviors as (resident 17's name) makes many comments about his roommate and status. DON and staff working on moving roommate to determine if this will assist in decreasing his agitation and outbursts with sexual behaviors. Every shift documentation monitoring an increase or decrease in behaviors to be completed due to increase in medication dose. *Substantiation and Action: -Was abuse/neglect allegation substantiated? Yes. -Why or Why not? Resident to resident sexual groping. *Was it a willful act? Yes. *Action taken by the facility: Personnel education and other were checked. *Other, please specify: Physician present at the time, new orders in medication, change in room mate. *No documentation to support: -Who the female resident was that he had physical contact with. -The cognition level of the female resident who was involved in that event. -Follow-up interviews with the staff members who had been involved or witnessed the event. -That an investigation and interview had been conducted with the resident or staff members who were touched by him in an inappropriate manner. Surveyor 2. Interview on 3/13/18 at 9:45 a.m. immediately following the resident council meeting with resident 49 revealed she: *Waited until all residents at the group meeting had gone. *Stated: -There is a guy here that grabbed me on the bottom the other day. -She had reported the incident to social services. -He makes me feel nervous. He goes all over the place and you never know what he is up to. -I try to avoid walking by him in the dining room or hall. -I don't know how long he is going to be here. -The staff talked to her about the incident and said they were going to report it to the state. -I don't know how many times he gets. It might be three strikes and you are out. -She felt very uncomfortable when he was around. Especially after he had grabbed her bottom in the dining room. *Agreed to have another surveyor visit with her about the above incident. Surveyor: 3. Interview on 3/13/18 at 2:26 p.m. with resident 49 revealed: *She had been: -The other resident mentioned in the 3/8/18 event with resident 17. -Coming out of the dining room after finishing her breakfast. -Watching for residents coming in and going out for safety purposes as it was crowded. -Coming out and resident 17 was going in to the dining room. *She stated: -He reached behind me and grabbed my left butt and squeezed a handful of it. -One of the male certified nursing assistants (CNA) (stated CNAs name) asked if I was alright. -I told him what happened and he said that wasn't right and would report it. -I went to my room for about thirty minutes to pull myself together and then went down to (name of social service coordinator) (SSC S) office and she was aware of it. -I was told he was taken out of the dining room and that he had hit the table hard with his cane. *He had not attempted to approach her before that day. *She stated I heard he has had hands on with other residents. *In the past she had tried not to come in contact with him. *She stated: -I felt very violated that day when he grabbed my butt. -It was a violation of my privacy especially at this age. -I shouldn't have to fear for that type of behavior from an old man in a place like this. -It was an invasion of my rights. -I haven't seen him or heard him be inappropriate with the others but I do hear the staff tell him hey stop that. -I have heard he can be grabby and at this age would never think of stuff like this, thinking and worrying of old people doing stuff like that. *She: -Had not been injured when he grabbed her buttock. -Stated It was very unsettling and I was embarrassed. I could feel my face turning red. Review of resident 49's medical record revealed: *A BIMS score of fifteen meaning she was alert and oriented to time, person, and place. *On 3/13/18 at 9:59 a.m. the social service coordinator (SSC) S had documented: -Late entry for 3/8(18). -(Resident's name) approached SS and stated that another resident was walking out of dining room and grabbed her bottom. -She was distressed. -SS calmed her down and apologized that she had to endure that. -SS assured her that our DON would file a state report, and that we would assure that this resident did not do that to her again. *The documentation by the SSC S on 3/13/18 had: -Occurred five days after the 3/8/18 event. -Been the only documentation and interview by administration regarding the 3/8/18 event involving resident 17. 4. Interview on 3/13/18 at 5:56 p.m. with an anonymous resident revealed he/she: *Had concerns regarding a male resident who walked around with a cane. *Stated: -He is mean to another resident and it's mostly when staff are not around. -He will hit her in the legs with his cane. -She is confused and doesn't say anything. -A few days ago I was in the lobby and he wanted her to do something or go somewhere and she wouldn't go. He then swatted her in the legs with his cane. -Now none of the other women will sit by him they are probably afraid of him. -I know I would be but he leaves me alone. *Had not reported that incident and others that had been witnessed to the staff. *Agreed those incidents should have been reported. *Stated Nothing will change if I do. Medical record review of the above resident revealed a BIMS score of fifteen. -That score supported there was no problem with memory recall. 5. Random observations starting on 3/12/18 at 11:45 a.m. through 3/15/18 at 9:30 a.m. of resident 17 revealed he had: *Been independent with ambulation. *Been able to ambulate throughout the building without difficulty. *Not required supervision or oversight by the staff while ambulating. *Required the use of an assistive device while walking. -That device had been a wooden, single-point cane. *Spent most of his time in the lobby area participating with activities. Observation and interview on 3/13/18 at 3:36 p.m. with resident 17 revealed he: *Had been sitting in his room watching television. *Was alert and pleasant to visit with. *Had remembered the event that occurred on 3/8/17. *Stated: -The other day the night nurse came in with meds, we got mad at each other and I'm not sure why. -She left and I went out to the dining room to eat. -The staff came and got me and gave me this shot, I thought I was dying but then I woke up. -The doctor was here and he helped them. -There was a lot of staff and they were grabbing me and my hands I have no idea why but there was a lot of them. -I get angry sometimes and not sure why. -I blackout and do things and can't remember them. *Several times he stated I have times where I black out and I can't remember the things I do. Review of resident 17's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had a BIMS score of twelve meaning he had moderate cognitive impairment. *He was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had: -The capability of wandering throughout the facility with a history of going into other residents' rooms. -A history of: --Verbal, physical, and sexually inappropriate behaviors towards residents and staff. --Taking scissors, finger nail clippers, and knives from the activities and dietary department. *The physician had assessed the resident every sixty days and as needed (prn) for any acute health care concerns identified by the staff. *The documentation from those physician's visits identified: -On 9/28/17: Follow up on chronic management of issues related to [MEDICAL CONDITION] associated with dementia and depression. He refers to himself as crazy. He says sometimes he voices or does crazy things. We have tried to taper quetiapine ([MEDICATION NAME]) and has had breakthrough symptoms that have really been distressing to other residents and staff and even to him. He is aware of the hallucinations and inappropriate behaviors. -On 11/9/17: In general terms we follow him for dementia and some associated behavioral issues with delusions and [MEDICAL CONDITION]. *He had been taking [MEDICATION NAME] 50 milligrams (mg) twice a day for [MEDICAL CONDITION] since 2/28/17. -A gradual dose reduction had been contraindicated d/t (due to) an increase in his behaviors would have occurred. *On 3/6/18 the physician had increased his bedtime dose of [MEDICATION NAME] to 75 mg d/t bizarre behaviors including some sexual references in front of the nurses. -Plan: We could make a small increase in quetiapine ([MEDICATION NAME]) dosage in the evening to try to help sleep better and see if this also helps him to control some of his impulsive behaviors sexual expressions. *The pharmacist had completed monthly chart reviews on the resident with recommendations made. -The physician had declined to attempt any further GDR on his [MEDICATION NAME] d/t a result of his behaviors worsening. Review of resident 17's nursing progress notes from 5/4/17 through 3/14/18 revealed: *On 5/14/17 at 12:26 p.m.: Resident assigned seating in dining area moved to table with peer secondary to inappropriate touching of female peer. Staff will continue to monitor. -There was no documentation to support: --What type of inappropriate touching had occurred. --An incident report and investigation had been completed on both residents to rule out abuse. --The female peer had been cognitively aware enough to give consent for that type of touching. --There had been no mental distress for the female peer after being touched inappropriately. *On 7/11/17 at 8:30 a.m.: the charge nurse had documented: CNA reported that resident was in dining room after breakfast and touched her inappropriately on chest and twice on the hip; CNA reported this to me and will document in behavior log as well. *On 7/20/17 at 10:55 a.m.: A quarterly assessment completed by the SSC S. She had documented he had minimal depression with a BIMS score of fifteen. That BIMS score was an improvement and indicated his memory recall was intact. He had no behaviors or [MEDICAL CONDITION] during her assessment period. -Her assessment period for review was 7/11/17 through 7/17/17. Those dates would have included the above incident on 7/11/17 involving inappropriate touching of a staff member. *On 7/24/17 at 8:20 a.m.: Hsk (housekeeping) staff states resident hit her on her side and she told him to stop and that it is not ok to do that and that he shouldn't touch her. He then put up a fist and said I'll hit you. I spoke with him and said that it is inappropriate to hit anyone and that he must not do that again. He stated understanding. *On 8/29/17 at 8:18 a.m.: CNA noted that resident was in the DR (dining room) attempting to kiss another female resident but she was vehemently stating 'no' to him. Intervened and stated to resident that that behavior is inappropriate and that female resident is stating no. This resident made a inappropriate facial gesture and said that 'I will get you next time.' I spoke to resident about the incident. Reinforced to him that he must not touch other residents. He states understanding at this time. *On 8/29/17 at 1:09 p.m. by the SSD, It was reported to SS that (resident 17's name) kissed a female resident on the cheek and put his arm around another female resident who told him to stop; (he did comply). SS talked with (resident 17's name) explaining that he could not touch any resident without their permission. He stated he understood and would stop. -No documentation to support: --An incident report and investigation had been completed on both residents to rule out sexual abuse. --There was no assessment for mental distress on the female peer after being touched inappropriately and kissed without her permission. *On 9/7/17: -At 9:21 a.m.: Activities staff person motioned me to the lobby as two residents (this male resident and a female resident) were having an altercation. Female resident had grabbed his stick that was used for exercise class and this resident responded by getting close to her and make gestures to her with his hand. I came and assisted the resident to have a seat in a different area, which he reluctantly did. The activities staff told me this resident had also grabbed her in an inappropriate body part a she was attempting to separate the residents. Staff was able to redirect him to sit in a different area, although resident did attempt to move back to female resident's chair, and then moved back to his chair. -At 9:55 a.m.: Staff reported that this resident again attempted to move back over to the female resident that he had altercation with. This resident then left the lobby and I spoke with him about the behaviors he was involved in. He indicated that 'it just starts.' I reinforced to him that he needs to not let it start. -An incident report and investigation had not been completed on both of the residents. -There had been an incident report completed on the female resident. *On 9/11/17 at 4:06 p.m. by the dietary director: It has been brought to my attention that (resident's name) slapped one of my staff on her bottom. It happened on Wednesday the 6(th) of September. This morning at breakfast when taking his order he hand signaled groping her chest. *On 9/29/17: He had several events of inappropriate behaviors with residents and staff. -At 11:03 a.m. the SSC S documented: SS heard yelling in the lobby this am. SS observed (resident 17's name) and female resident standing facing each other. A CNA who is a Spanish speaker began to assess the situation with (resident 17's name). (Resident name) stated that this 'crazy lady' stood up and begain (began) yelling at him. He states he did not make jabbing motions with his cane at her, and that he did not touch her or attempt to. He started yelling when she did because he wanted someone to help him in the situation. -At 1:36 p.m.: Bath aide asked me to come into the tub room. She states this resident has been talking mean to her and calling her a liar. I spoke with this resident and asked him not to speak inappropriately or mean to anyone. He did not respond as to whether he would cooperate or not. Bath aide will report any further behavior issues. -At 3:45 p.m. the SSC S documented: CNA and her supervisor approached SS this afternoon report (resident' name) had been verbally aggressive and demeaning to CN[NAME] She was in tub room with (resident's name) giving him a bath and he appeared upset; he began saying inappropriate comments, and humiliating racial comments to aide. He then began to state that the aide was pretty when she was mad. She asked him to stop and stated she would get a nurse. He stated he didn't care because all of you are a bunch of witches. He continued to make personal, racial statements to CN[NAME] This writer advised that she not continue working on his hall as this was a very upsetting incident for her. SS reported to DON. Nursing will f/u (follow-up) with this situation monitoring (resident's name) behavior. -No documentation to support: --When the nursing department had investigated the above situations from 9/29/17. --What further action the nursing department had put in place after their investigation and review of the above incidents involving the resident. *On 10/8/17 at 8:00 a.m.: Resident became physically combative when he grabbed public restroom key and was told by CNA he was only to use restroom in own room; struck at CNA with clenched fist, hollering that he wanted to use public bathroom. Kicked at door of bathroom when key was taken. Reminded that bathroom in his own room was only part way down hall. Behavior remained verbally hostile for several moments. *On 10/16/17 at 1:09 p.m.: A quarterly assessment had been completed by the Minimum Data Set (MDS) assessment coordinator. She had documented He is currently receiving antipsychotic and antidepressant medication daily. In review of documentation, his provider documentation of 9/28/17 notes that his recommendation to remain at the current dose of [MEDICATION NAME] at 50 mg is effective and this was increased in February, resident does not want this dose changed as per provider documentation on the above date. Assessment completed and care plan updated. Continue to monitor for needs and changes in status. *On 10/17/17 at 1:21 p.m.: A quarterly assessment had been completed by the SSC S. She had documented a decline in his BIMS score from 15 to 12. That score indicated his memory recall was moderately impaired. *On 12/1/17 at 11:38 a.m.: Bath aide reports that this resident made multiple sexually inappropriate comments to her as she was assisting him with bathing in tub. I spoke to him, asking him to please not use that type of language with staff or anyone. He states he can't help what he says and that it just happens. *On 12/3/17 at 10:30 a.m.: CNA reported that this resident spoke inappropriately to her this a.m. I asked him to please not speak to any staff in this way. He states he can not help it when he does it, it just happens. *On 12/6/17 at 10:28 a.m. refer to the above online reporting form. *On 12/7/17 at 8:00 a.m.: As aide was walking into the resident's room to answer other resident's light, this resident put his hand on the aide's lower back and pushed aide saying they were in his way. Aide asked this resident to please not touch me. Then this resident put his fists up as if he was ready to fight. Aide asked this resident to please go ahead and enter the restroom where he was and leave the room and told aide to take her pants off and get into the roommates bed and give him some (foul language). Aide and roommate asked this resident many times to please stop and enter the restroom, when finally he did. -No documentation to support: --An incident report and investigation had been completed to ensure no type of abuse had occurred. --Further action had been completed by the SSC S, administration, and IDT to ensure the roommate's mental status had not been effected by the resident's verbal and physical behaviors towards himself and the staff. *On 1/8/18 at 1:09 p.m.: A quarterly narrative had been completed by the SSC S. -No documentation to support: -The inappropriate behaviors the resident had exhibited above since his last assessment. -What action had been taken to ensure the mental and physical safety well being had occurred for all residents and staff involved. *On 1/10/18 at 12:37 p.m.: A quarterly narrative had been completed by the MDS assessment coordinator. Usually calm and cooperative, but he does have episodes of inappropriate behaviors and sexually explicit comments towards staff. Usually is redirectable. (Physician's name) documented in (MONTH) that a decrease in the resident's [MEDICATION NAME] and [MEDICATION NAME] causes decompensation of his behaviors. Last period of episode was 12/7/17. *On 1/19/18 at 10:48 a.m.: Bath aide reported that patient said, That she better have her papers and that she was illegal immigrant. DON was notified of the comments by bath aide. DON lets the resident know that his comment was not appropriate and that is not ok to talk to staff in that way. Nurse called daughter, no answer at this time, left VM (voicemail) to call the nurse back at the facility. The call was to inform family of the patient behaviors. *On 1/22/18 the staff had reported the resident going into other resident's rooms to use their bathroom. *On 2/9/18 at 11:48 a.m.: Resident tried to swat CNA on rear end, CNA dodged, and resident tried to strike CNA with fist. *On 3/6/18 refer to the above incident reporting form. *On 3/8/18 refer to the above online reporting form. *On 3/14/18: -At 5:08 p.m.: Resident told female peer, when she stood up from dinner table to go on and get out of here. Female peer responded, 'shut up and leave me alone.' This resident then said, 'I said go on and get the (foul language) out of here.' This resident will be moved to another dining table away from female peer effective next meal. Staff will continue to monitor. -At 6:39 p.m. the SSC S documented: It was reported to SS that (resident 17's name) had made inappropriate comment to female resident in dining room. SS went to his room much later to interview him; asking if anything happened in the dining room tonight and he related the following: Nothing happened in the dining room tonight. Sometimes I say things that get me into trouble. I get moved all the time in the dining room. I was sitting with a lady that is skin and bones and she won't eat, just falls asleep. I saw an empty table so moved my stuff to the table in the back of the room. I like to eat by myself. A lady at the next table got up and was mad and stared at me and left; The other ladies were talking bad about me too. I don't remember what I said or what she said. SS informed (resident's name) that he would not be sitting close to those ladies anymore as it wasn't working out for anyone. He said he was sorry. SS talked with nurse to make sure family was notified of alleged incident. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse. -The physician and family had been notified after each above event. -What interventions had been put in place to ensure that type of behavior exhibited by the resident would not have occurred again. -The inappropriate verbal, physical, and sexual behaviors exhibited above by the resident had been reviewed in fu", "filedate": "2020-09-01"}
{"rowid": 40, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 609, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and policy review, the provider failed to investigate and report incidents with injury for 4 of 13 sampled residents (17, 41, 42, and 53) according to South Dakota Department of Health (SD DOH) guidelines. Findings include: 1. Review of resident 41's medical record, incident reports, and investigations from her admission on 8/1/17 through 3/15/18 revealed:*She was cognitively impaired and had multiple falls and injuries. *She was dependent on staff for assistance with personal care. *On 10/24/17 she had a fall that resulted in a right shoulder dislocation and had to be sent to the hospital for treatment. -That fall had no investigation and had not been reported to the SD DOH. *On 1/7/18 she was involved in a resident-to-resident altercation. -That incident had no investigation and had not been reported to the SD DOH. *On 1/22/18 she had a bruise found on her left great toe that was of unknown origin. -There was no investigation to rule out abuse, and that had not been reported to the SD DOH. *On 2/19/18 discoloration was noted to the back of her head, both heels, and buttocks during a bath. -There was no investigation into those areas, and they had not been reported to the SD DOH. --The heels were later identified as pressure injuries. *On 2/26/18 a blister-like spot was noted to the tip of her right great toe. -The nurse wrote .not going to classify as pressure area . -There was no investigation into the cause of that area, and it had not been reported to the SD DOH. Refer to F610, finding 10. 2. Review of resident 53's medical record, incident reports, and investigations from his admission on 2/14/18 through 3/15/18 revealed:*He had cognitive impairment and was dependent on staff for personal care. *On 2/22/18 .Bruised area to left shin measuring 2.1 cm (centimeters) x (by) 1.1 cm covered with ABD pad and cling to secure for protection. -There was no mention of how that bruise occurred or if it was a new area. -There had been no incident report for that injury. *On 2/26/18 .Has blood blister like area 1.7 x 1.0 left lower shin with tx (treatment) for protection started . -There was no mention: --If that was the same area identified on 2/22/18 or if it was a new area. --How the blood blister occurred. -There had been no incident report for that injury. *On 3/4/18 he had an unwitnessed fall in his room where CNA's found resident on floor beside bed- resident c/o (complained of) rib and back pain. Resident stated 'I was trying to go home. -He was sent by ambulance to the hospital and returned to the facility later that day. *On 3/8/18 Resident has two small skin tears to left hand cause unknown. *For all the above injuries there was no documentation to support an investigation to rule out abuse had been done. -None of them had been reported to the SD DOH. Refer to F610, finding 11. 3. Review of resident 17's medical record, incident reports, and investigations during the survey on 3/12/18 through 3/15/18 related to his verbal, physical, and sexually abusive behaviors involving other residents and staff members revealed he: *Had [DIAGNOSES REDACTED]. *Had a Brief Interview for Mental Status score of twelve meaning he had moderate cognitive impairment. *Was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had multiple incidents of inappropriate behaviors with other residents and staff. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse/neglect. -The physician and family had been notified after each above event. -What interventions had been put in place to ensure that type of behavior exhibited by the resident would not have occurred again. -The inappropriate verbal, physical, and sexual behaviors exhibited above by the resident had been reviewed in full to ensure the mental health, personal privacy, residents' rights, and dignity was maintained for all who had been involved in those altercations. *Multiple incidents had not been reported to the SD DOH. Refer to S550, findings 1, 2, and 3. Refer to S600, findings 1, 2, 3, and 4. 4. Review of resident 42's medical record, incident reports and investigations from his admission on 2/7/18 through 3/15/18 revealed: *He was cognitively impaired and had multiple falls and injuries since 3/2/18. *He was dependent on staff for assistance with personal care. *On 3/2/18 he had a fall that resulted in right hip pain and was sent to the emergency room for evaluation. -That fall had not been reported to the SD DOH. -A limited investigation had been indicated on the incident report. *On 3/12/18 he had a fall that resulted in a laceration above his right eye and he was sent to the emergency room . -That incident had no investigation and had not been reported to the SD DOH. Refer to F610, finding 13. Refer to F758, finding 1. Surveyor: 5. Interview on 3/14/18 at 3:05 p.m. with the administrator, director of nursing, Minimum Data Set coordinator, and social services coordinator S regarding residents' incidents and investigations revealed: *The incident reports and investigations were all together on the incident report forms. *If the surveyor had not been given the Required Healthcare Facility Event Reporting forms then the incident had not been reported to SD DOH. *Incidents that involved a major injury to the resident or required transfer to another facility for treatment should have been reported to SD DOH. *Any injuries of unknown origin should have had an investigation to support abuse had or had not occurred. Review of the provider's 6/27/16 Abuse Investigations policy revealed: *All reports of resident, abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. *The staff conducting the investigation should have: -Reviewed the completed documentation forms. -Reviewed the resident's medical record to determine events leading up to the incident. -Interviewed the person(s) reporting the incident. -Interviewed any witnesses to the incident. -Interviewed the resident (as medically appropriate). -Interviewed the resident's physician as needed to determine the resident's current level of cognitive function and medical condition. -Interviewed staff members (on all shifts) who had contact with the resident during the period of the alleged incident. -Interviewed the resident's roommate, family members, and visitors. -Reviewed all events leading up to the alleged incident. *Each interview should have been conducted separately and in a private location. *The results of the investigation should have been recorded on approved documentation forms. *The DON or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.", "filedate": "2020-09-01"}
{"rowid": 41, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 610, "scope_severity": "F", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and policy review, the provider failed to complete and fully investigate residents' incidents for 13 of 13 sampled residents' (3, 5, 6, 17, 33, 36, 37, 41, 42, 47, 53, 57, and 109) reviewed with incident reports and investigations. Findings include: 1. Review of resident 3's fall incident investigation reports revealed: *A fall report dated 7/11/17 completed by registered nurse (RN) G stated the resident had:-Fallen onto her bottom in the bath house. -The following areas on the incident investigation report had not been completed: --Mental status. --Physiological factors. --Predisposing situation factors. -There had been only one fall progress note regarding the 7/11/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/18/17 completed by licensed practical nurse (LPN) N stated the resident had: -Fallen when She missed the toilet and fell straight on her butt. Denies hitting head. -The following areas on the incident investigation report had not been completed: --Injuries Observed at Time of Incident. --Level of pain. --Mental status. --Predisposing environmental factors. -There had been only one fall progress note regarding the 7/18/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/20/17 completed by RN T stated the resident had: -Been found by staff sitting on the middle of the floor in her room. She denied hitting her head. She stated I was getting up to ask someone about lunch. -The following areas of the incident investigation report had not been completed: --Injury type No Injuries observed at. --Mental status. --Predisposing environmental factors. --Predisposing situation factor. -There had been no fall progress notes regarding the 7/20/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/29/17 completed by RN T stated, Resident was being transported back from being hospitalized at CRH (Custer Regional Hospital). She was in w.c. (wheel chair) and being assisted into van via lift operated by staff. She brushed her left arm on the lift control that caused it to start and she bumped her head on the doorway of the van. she was taken back into the ER and Dr (name) assessed and placed a gauze/Coban dressing over it. New orders were received from Dr (name) for wound care. -The following areas of the incident report had not been completed: --Mental status. --Predisposing environmental factors. --Predisposing physiological factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 7/29/17 incident in her medical record. -There had been no documentation of an investigation having been completed. 2. Review of resident 33's fall incident investigation reports revealed: *A fall report dated 10/30/17 completed by RN T stated, Resident was using her walker and was preparing to sit in one of the chairs in the area by hall 3 exit door and as she was backing up to sit down in chair she slid down the front of chair and was found sitting on the floor. Denies pain and able to move all extremities. Denies hitting her head. Resident's POA (power of attorney) arrived for a visit just after the fall. Able to ambulate without difficulty following the fall. -The following areas of the investigation report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing physiological factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 10/30/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 11/15/17 completed by LPN M stated, Resident was in assisted in dining room when she had her walker against another resident's wheelchair. When the resident in the w/c started moving her walker rolled and she fell to her knees. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. -There had been only one fall progress note regarding the 11/15/17 incident in her medical record. -There had been no documentation of an investigation having been completed. 3. Review of resident 47's fall incident investigation reports revealed: *A fall report dated 2/8/18 stated. Resident found to be sitting on the floor with her legs bent and feet not on the floor. Resident had no shoes or slippers on, just TED hose. Resident had previously been noted to be sleeping in her recliner by writer and CN[NAME] Resident stated she woke up and did not know where she was, and turned over. Resident states she then fell out of the chair and had been crawling on floor trying to get up. States knees hurt from crawling on floor. Denies any other pains or complaints. -The following areas of the incident report had not been completed: --Mental status. --Predisposing environmental factors. -There had been only the initial fall note on 2/818 identified in the resident medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 2/9/18 completed by RN U stated, Sitting in recliner and slid to the floor while trying to get out of recliner to plug in her cell phone. denies hitting head. Resident was talking on phone with family while incident happened. Family called this nurse to let us know that her mother needed her cell phone plugged in and that she had slipped onto the floor. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing situation factors. --Notes. -There had been only the initial fall note on 2/9/18 identified in the resident's medical record. -There had been no documentation of an investigation having been completed. 4. Review of resident 57's fall incident investigation reports revealed: *A fall report dated 5/11/17 completed by RN T stated Resident fell against wall in DR (dining room) as he was standing up and getting ready to leave. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environment factors. --Predisposing situation factors. --There had been only the initial fall note on 2/9/18 identified in the resident's medical record. *A fall report dated 12/30/17 completed by RN T stated, CNA reports resident was as being transferred from toilet to w.c. He was holding onto handle bar as the CNA was bringing the w.c. into the bathroom for the resident to be seated on. Resident lowered self down to floor before CNA was able to lock the brakes. He was able to to continue holding on to the handle bar attached to wall while lowering self and siting on floor with feet on floor. -The following areas of the incident report had not been completed: --Level of pain. --Mental status. --Predisposing environmental factors. --Predisposing situation factors. -There had been no fall progress notes regarding the 12/30/17 incident in the resident's medical record. -There had been no documentation of an investigation having been completed. 5. Interview on 3/28/18 at 8:30 a.m. with the director of nursing revealed she: *Agreed the incident investigations for residents 3, 33, 47, and 57 were incomplete. *Expected the incident reports and fall progress notes to be completed. *Expected the nurses to begin a fall investigation. 6. Review of resident 17's medical record, incident reports, and investigations during the survey on 3/12/18 through 3/15/18 related to his verbal, physical, and sexually abusive behaviors involving other residents and staff members revealed he: *Had [DIAGNOSES REDACTED]. *Had a Brief Interview for Mental Status score of twelve meaning he had moderate cognitive impairment. *Was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had multiple incidents of inappropriate behaviors with other residents and staff. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse/neglect. -The physician and family had been notified after each above event. -What interventions had been put in place to ensure that type of behavior exhibited by the resident would not have occurred again. -The inappropriate verbal, physical, and sexual behaviors exhibited above by the resident had been reviewed in full to ensure the mental health, personal privacy, residents' rights, and dignity was maintained for all who had been involved in those altercations. Refer to S550, findings 1, 2, and 3. Refer to S600, findings 1, 2, 3, and 4. 7. Review of resident 6's medical record revealed: *An admission date of [DATE]. *She had short and long term memory problems and was not interviewable. *Her [DIAGNOSES REDACTED]. *She was able to walk independently without the use of an assistive device. *She had: -Required staff supervision d/t poor decision making capabilities. -Been able to wander throughout the facility. -A history of attempting to elope from the facility. *No documentation to support her elopement from the building on 1/13/18 had been investigated and reported to the SD DOH. Review of resident 6's incident reports that included the investigations from 9/18/17 through 3/9/18 revealed: *She had made several attempts to leave the facility. *On 9/18/17 at 6:03 p.m. she had opened the exit door on hallway two. An unidentified CNA followed her outside and was able to redirect her back into the facility through another exit door. *On 10/20/17 at 10:28 p.m. she had an unwitnessed fall in her room. The staff found her sitting on the floor by her roommates bed. Her pants and incontinent brief were down, and there was bowel movement on the floor. No injury identified. *On 12/27/17 at 2:55 a.m. she had opened the exit door on hallway two and went outside. By the time the charge nurse arrived at that exit door the resident was walking down the sidewalk. She was half way to the parking lot by the time the charge nurse was able to reach her. She only had on pajamas, socks, and shoes. The charge nurse was able to redirect her back into the facility. *On 1/13/18 at 5:52 p.m. she had opened hallway one's exit door. The alarm sounded, but by the time an unidentified CNA got to the door she was out of her sight. The CNA did not open the door and do a complete check to ensure no one was outside of the building. When the CNA looked straight out the door she had not seen anyone. The resident was able to walk down the sidewalk and into the visitor parking lot. A visitor had been coming back into the building and brought her with them. The temperature was documented in the mid-thirties. *On 2/28/18 at 2:16 p.m. she went outside through hallway two's exit door. Staff were able to redirect her back into the building. *On 3/1/18 at 9:49 a.m. the maintenance staff had been testing the door alarms. She attempted to go outside hallway two's exit door. The door alarm sounded, and the staff had been able to redirect her back into the building. *On 3/9/18 at 5:55 p.m. she attempted to sit down on the floor when the staff were walking her out of the dining room. The staff lowered her to the floor with no injury. *For all of the above incidents and investigations there was no evidence to support a thorough investigation had occurred. -There were multiple areas of missing documentation in the incident reports. *The documentation had not supported: -That a root cause analysis of the reports had been determined. -The facility response and action plan to ensure she had been safe without the inability to elope from the building. *The incident reports failed to consistently identify: -Mental status at the time of the events. -Predisposing environmental factors. -Predisposing physiological factors. -She was an active exit seeker under predisposing situation factors. Interview on 3/28/18 at 3:10 p.m. with the administrator regarding resident 6 confirmed they had identified her as a safety risk. He had been reviewing an alarming/locking system for the exit doors. He had recently received permission from the manager of Regional Health Systems to install a Wander Guard system. -That system would start with the new budget starting 7/1/18. Review of the provider's 6/27/16 Elopement/Elopement Attempts policy revealed: *(Facility name) strives for resident safety. Nursing personnel must report and investigate all reports of missing residents. *Upon return of the resident to the facility, the staff nurse should: -Examine the resident for injuries, notify the physician, and representative. -Update resident's care plan to reflect interventions implemented. -Complete initial report to South Dakota Department of Health online. 8. Review of resident 5's medical record revealed:*She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was moderately impaired. *Her [DIAGNOSES REDACTED]. Review of resident 5's incident reports including the investigations from (MONTH) (YEAR) through 3/12/18 revealed:*On 10/5/17 she had physical behaviors of hitting her roommate. *On 10/18/17 she had an unwitnessed fall. *On 11/3/17 she had gone outside and was found in the parking lot after the door alarm rang. *On 11/19/17 she had an unwitnessed fall and hit her head. *On 11/28/17 she had an unwitnessed fall. *On 12/18/17 she had a witnessed fall in the lobby during activities where she tripped over another resident's walker. *On 1/16/18 she had a witnessed fall in the lobby when she tried to pick something up off the floor. *On 2/21/18 she had an unwitnessed incident where she was found to be chewing on a box of tissues and had a tissue in her mouth in the lobby. *On 2/28/18 she had an unwitnessed fall in the lobby and had redness on her cheek and left arm from it. -There was no mention of the physician having been notified. *On 3/3/18 she had an unwitnessed fall in the lobby during a movie activity. *For all of the above incidents and investigations there was no evidence to support a thorough investigation had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 9. Review of resident 37's medical record revealed:*She had been admitted on [DATE]. *Her 8/24/17, 11/7/17, and 2/7/18 Brief Interview for Mental Status examination scores indicated she had moderate to severe cognitive impairment. *Her [DIAGNOSES REDACTED]. Review of resident 37's interdisciplinary behavior progress notes from her 8/18/17 admission through 3/28/18 revealed:*On 8/23/17 she .became upset and pushed CNA out of the room . *On 10/5/17, CNA overheard this resident tell her roommate 'stop hitting me.' CNA was outside of room and did not witness this resident being hit. Resident states she did not get hurt, assessed and no injury noted. CNA redirected the roommate of this resident out of the area. *On 11/1/17, At pm meal this resident attempted to make her tablemate put his nasal cannula back on, telling him that he had to and she knew so because she once worked her. When this nurse intervened to separate this resident and her tablemate this resident became very angry striking out at this nurse then grabbing my arm and trying to yank me around. This nurse to resident 'that's enough, take your hands off me and don't touch me like that, it's not acceptable' Resident began to yell again that she can do what she wants because she once worked here. Tablemate removed and placed at a different table secondary to this resident would not calm down and quit yelling. This resident struck out at and grabbed this nurse 2 more times. Staff will continue to monitor. *On 11/7/17, At app. 1015 this am this resident was sitting in a chair, and approached by another resident. This resident started yelling at the other resident, telling her to sit down. The other resident did not sit down, so this resident then took her by the hand and physically sat her down in the chair. She then yelled 'I used to work here, and you stay there!' This resident was then educated on not touching others. She kept repeating but 'I used to work here, I was a CNA!' I explained to her that she no longer works here, and cannot touch other residents. She then promised that she wouldn't do that again. *On 11/20/17, CNA informed this nurse that the resident has been having behaviors of: Wandering into other resident's rooms, attempting to help residents out of bed (even residents that require extensive/dependent assist), taking items and clothing that do not belong to her. Refusing to change clothes even after wearing the same clothes for days . *On 12/17/17, This nurse heard resident yelling at her roommate. Upon entering her room this resident had privacy curtain pulled around her roommates side of the room and had resident cornered yelling at her. This nurse told this resident that she needed to go back to her side of the room. Resident swung her arm at me and yelled that she was a CNA here and that she could do as she wished. I again told resident to go to her side of the room and keep her hands to herself. Resident continued to yell and tried x4 to grab this nurse. Resident eventually did go and sit on her bed but continue to yell out until staff left room . *On 12/31/17 two notes: -Resident yelling at roommate, stating roommate was in her room . -Second episode of behaviors this shift. Resident again yelling at roommate as roommate was playing with the cables at the midway point of the room. Resident could be heard by writer near nurse's station . *On 3/23/18, CNA reports resident has items of clothing that belong to her roommate. When the CNA asked her about it, this resident started yelling at the CNA and hit her on CNA's rt (right) hand . On 3/28/18 at 9:25 a.m. copies of incident reports and investigations for resident 37 were requested from the director of nursing support person B. Interview on 3/28/18 at 12:50 p.m. with the DON regarding resident 37 revealed: *No incident reports or investigations were completed for the resident from her 8/18/17 admission through 3/28/18. *She confirmed events that included resident-to-resident altercations should have had incident report and investigations. *For the above behaviors and events there was no evidence to support a thorough investigation had occurred. *The documentation had not supported that: -Staff had been interviewed to give details related to each event. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 10. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. Review of resident 41's incident reports including the investigations from her admission on 8/1/17 through 3/12/18 revealed: *On 8/3/17 she had an unwitnessed fall between the office and the dining room and had hit her head causing a cut to her left eyebrow. *On 8/15/17 she had an unwitnessed fall in the hallway near the vending machines. -There was no mention of notification to her family. -There were notes several days later on 8/21/17, 8/28/17, and 9/6/17 from fall meetings. --Those notes did not include investigation specific related to each fall that occurred. *On 9/7/17 she was seen going out an exit door. *On 9/12/17 she had an unwitnessed fall in her room. -There was no mention of notification to her family. *On 9/25/17 she had an unwitnessed fall in her room, hit her head causing a laceration to her right forehead, and was sent to the emergency room for evaluation by ambulance. -There were notes on 9/27/17, 10/2/17, and 10/4/17 that included: -- .CNA says that resident appears to become more agitated and impulsive towards the evenings. Note left for Dr. (name). Nurse encouraged to use her PRN [MEDICATION NAME] if other interventions are not successful. -Review of the final Required Healthcare Facility Event Reporting form for the 9/25/17 event indicated: --In the brief explanation: .It was noted that (name) was wearing shoes and had just minutes before had been seen walking to her room from the nurses station . --There was no mention if her care plan had been followed since she required staff assistance with walking. --The conclusionary statement stated she had a short hospital stay for observation and received stitches to her laceration. -Action taken was personnel education. --Which staff and what education was done was not specific related to the resident's incident. --There was only mention of a nurse who completed the wrong report for the department to get education. *On 9/29/17 she had a witnessed fall by the door of the dining room. -There was no mention of the physician being notified until a note on 10/4/17. *On 10/6/17 she had an unwitnessed fall in her room and pulled a shelf down in her room. -There was no mention of notification to her family. *On 10/10/17 she had a witnessed fall when attempting to walk without her walker. *On 10/13/17 she had a near fall in the commons areas for staff outside of the dining room. -There was no mention of how she got into that commons area. *On 10/24/17 she had an unwitnessed fall in the dining room and injured her right shoulder/arm. She was sent to the emergency room by ambulance. -A note several days later on 10/30/17 stated, Resident prior to fall was in the dining room per staff with a pink bucket (basin). This is not per interview with staff a Witnessed fall. Staff did administer PRN medications when resident became agitated and not redirectable in the most recent past. --That note was unclear as to when/how the information was obtained. -A note almost two months later on 1/17/18 stated Fall team met and discussed falls on 12/13/17, 12/17, 1/02/18, and 1/7/18. Resident is on Restorative program for ambulation and is working with therapy on improving toileting with verbal cues, hygiene and self feeding. Is on Q (every) 2 hour toileting, Q 2 hour resident checks. -There was no mention of the resident having a right shoulder dislocation as found during her emergency room evaluation. --The above fall with major injury and transfer to the hospital for evaluation had not been reported to the South Dakota Department of Health (SD DOH). *On 11/7/17 she had a witnessed fall in the hallway near the dining room where she hit her head and left elbow. -There was no mention of notification to her family. *On 12/13/17 she had a witnessed fall in the lobby and bumped her head. -A note over a month later on 1/17/18 was the same as the 10/24/17 fall. *On 12/28/17 she had an unwitnessed fall in her room with the following documented: - resident laying on ground, next to bed, with gown off and brief pulled down, bed wet. CNA had last been in room [ROOM NUMBER] minutes prior, doing safety check, and at that time resident was asleep. Resident bed in low position, floor mat next to bed (under resident). -There was no mention of when she had last been assisted to the bathroom. -A note several weeks later on 1/17/18 was the same as the 10/24/17 fall note. *On 1/3/18 a witnessed fall sliding from her low bed onto her fall mat. -The note several days later on 1/17/18 was the same as the 10/24/17 fall note. *On 1/7/18 she had an unwitnessed fall in her bathroom. -The description was Resident states 'I fell and hit my back here.' pointing to the bathtub. Resident was sitting on toilet, pull up wet. --There was no mention of when she had last been assisted to the bathroom. -Ten days later on 1/17/18 the note was the same as the 10/24/17 fall note. *On 1/7/18 she had a physical altercation with another resident in the lobby area that was witnessed by a third resident. -A note several days later on 1/23/18 stated, Resident placed on 30 minute status location monitoring. --There was no mention of how long those 30 minute checks would remain in effect. *On 1/22/18 the resident had a bruise-like area to the end of her left great toe. -There was no mention of how that bruise might have occurred or if any staff were interviewed about the injury. *On 1/31/18 she had an unwitnessed fall in hall outside her room with injuries with the following documented: - .resident laying on her left side with blood coming from her left eyebrow and mouth. ROM (range of motion) completed to all but resident's left arm secondary to resident yelling out in pain saying, 'don't touch it, it's broke.' Staff assist x 3 with gait belt to get resident to stand and place in a W/C . -She was sent to the emergency room by facility staff and van. -A note over a month later on 3/1/18 stated Pressure alarm placed with family consent to alert staff of attempt to transfer without assist . -Review of the final Required Healthcare Facility Event Reporting form for the 1/31/18 event indicated: --In the brief explanation: .CNA report that they had just checked on resident 5 minutes prior and she was in bed napping . --There was no mention if her care plan had been followed since she required staff assistance with walking and toileting. --The conclusionary statement stated Investigation is ongoing per DON. Resident returned from hospital on [DATE] @ 16:10 (4:10 p.m.) with dx (diagnosis) of fx (fracture) to L elbow .Staff per investigation, state she was sleeping in her bed only five minutes prior to her being found on floor .Resident had not been ambulating recently due to medical diagnosis .Facility and staff have tried every available option for decreasing her fall risk for example anti roll back on w/c, providing activity/diversion with any increased agitation that was not easily redirected. Primary provider and family discussion with nursing on 2/2 and decision to initiate pressure alarm to alert staff of resident attempts to self transfer to decrease her risk of falls . -Action taken was other: Discussion with family and Physician on safety concerns. *On 2/19/18 nursing found discoloration areas to the back of her head, both heels, and buttocks. -Immediate action taken was new mattress applied, foam boots and cream to buttocks applied.-Injury type was unable to determine for all four areas. -There was no mention of how those areas might have occurred. *On 2/26/18 nursing found .a softer absorbing blister like spot, tan/brown in color, soft at tip of toe. Wears only slipper socks and foam boots. Not going to classify as pressure area at this time. Treatment in to monitor daily. Area measures 1.3 x (times) 1.0 (centimeters). -There was no mention of how that blister like spot could have occurred. *For all of the above incidents and investigations there was no evidence to support thorough investigations had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. Review of resident 41's interdisciplinary progress notes revealed: *She had an unwitnessed fall on 11/9/17 in the hallway. -She received a skin tear. *She had an unwitnessed fall on 11/30/17 in her bathroom. *Those falls had not been part of the incident or investigation forms. 11. Review of resident 53's medical record revealed: *He had been admitted on [DATE]. *He had short term memory problems and severely impaired decision making ability. *His [DIAGNOSES REDACTED]. Review of resident 53's interdisciplinary progress notes from his 2/14/18 admission through 3/15/18 revealed:*On 2/22/18 .Bruised area to left shin measuring 2.1 cm (centimeters) x 1.1 cm covered with ABD pad and cling to secure for protection. -There was no mention of how that bruise had occurred or if it was a new area. *On 2/26/18 .Has blood blister like area 1.7 x 1.0 left lower shin with tx (treatment) for protection started . -There was no mention: --If that was the same area identified on 2/22/18 or if it was a new area. --How the blood blister had occurred. -On 3/12/18 that area was opened. *On 3/12/18 .Has skin tear on right wrist . -There was no mention: --If that was a new skin tear. --How the skin tear had occurred. *The above injuries were of unknown origin and had no incident or investigation reports related to them. Review of resident 53's incident reports and investigations from his admission through 3/15/18 revealed:*On 3/4/18 he had an unwitnessed fall in his room where CNA's found resident on floor beside bed- resident c/o (complained of) rib and back pain. Resident stated 'I was trying to go home. -There was no mention of: --How he might have gotten out of his bed to the floor. --What happened after he was sent to the hospital. -That event had not been reported to the SD DOH. *On 3/8/18 resident has two small skin tears to left hand cause unknown. -There was no mention of: --Witnesses. --Notification to his physician or family. --What might have caused those skin tears. *On 3/10/18, Resident presents with open pressure ulcer to the right shoulder no drainage [MEDICATION NAME] applied.-There was no mention of: --Witnesses. --Notification to his family. --What might have contributed to that pressure ulcer. *For all of the above incidents and investigations there was no evidence to support thorough investigations had occurred. -There were areas of missing documentation in the incident reports. *The documentation had not supported that: -Staff had been interviewed to give details related to the incidents. -A root cause of the incident had been or could have been determined. -Potential abuse had been ruled out. 12. Interview on 2/14/18 at 1:21 p.m. with licensed practical nurse (LPN) A and registered nurse (RN) G regarding residents' incidents including falls, resident-to-resident altercations, and injuries of unknown origin revealed: *LPN A was a traveling nurse and had worked in the facility for about one month. *RN G had been working in the facility for about a year. *They stated when a fall or incident had occurred with a resident the nurse should have: -Assessed the r", "filedate": "2020-09-01"}
{"rowid": 42, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 657, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure 6 of 13 sampled residents (5, 21, 33, 37, 41, and 53) had their care plans followed, updated, and revised timely to reflect their current status and care needs. Findings include: 1. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 5 revealed:*Her 3/27/18 care plan had not been updated timely related to her falls and interventions for them. Refer to F689, finding 2. 2. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 41 revealed her 3/14/18 care plan had not been: *Updated timely related to her falls and interventions for them. *Updated to reflect her current physician's orders [REDACTED]. *Followed by staff related to her fall and pressure ulcer interventions. Refer to F686, finding 1. Refer to F689, finding 1. Observation, interview, and review of the CNA cheat sheet on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during and following resident 41's personal care revealed: *The resident was wearing compression stockings to both legs and slipper socks on her feet. *She had no dressings in place to both of heel pressure injuries. -CNA I was not aware she was supposed to have dressings on her heels. *She was not wearing the foam boots that morning. -The CNA thought she only needed to wear her boots when she was in bed. *The CNAs used a cheat sheet as a reference for how to take care of the residents. *She was the person who updated those cheat sheets with input from the nurses. *CNAs also had access to review the residents' care plan in the electronic medical record. *She agreed residents' care plans and cheat sheets should have been updated to their current status and needs. *The cheat sheet for resident 41 included: -[NAME] hose on left leg only. -No mention of her pressure injuries or that nurses did a treatment for [REDACTED]. -No mention of the foam boots or when she should have worn them. Observation and interview on 3/13/18 at 11:17 a.m. with registered nurse (RN) [NAME] and licensed practical nurse (LPN) D in resident 41's room following her personal care revealed: *Her care plan was not being followed related to her pressure injuries. *She should have been wearing foam boots at all times, and she had not been wearing them that morning. *She was supposed to have dressings in place to both heels, and those had not been on. *The foam boots to her feet were for pressure relief related to pressure injuries on both of her heels. *They confirmed the CNA's cheat sheet had not reflected the appropriate interventions. *The resident's care plan should have been current to her status and need and followed by staff. 3. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *She had been moved from one room to another on 9/18/17 due to concerns with her rummaging through her roommates belongings. -On 10/5/17 she was involved in an incident with her current roommate where she was being hit by her. *Her [DIAGNOSES REDACTED]. *She had been on an antidepressant ([MEDICATION NAME]) since 11/22/17. -On 3/14/18 another antidepressant ([MEDICATION NAME]) had been ordered as well. Observations on 3/27/18 from 11:45 a.m. through 6:00 p.m. of resident 37 revealed: *She was independently ambulatory throughout the building. *Her overall demeanor appeared pleasant that afternoon. Review of resident 37's 2/7/18 quarterly Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status examination score was eight indicating she had moderate cognitive impairment. *She had no [MEDICAL CONDITION]. *During the lookback period she had: -One to three days of verbal behaviors only. --There was no impact on her or others. -She had rejected care one to three days. Review of resident 37's CNA task documentation related to her behaviors for the previous thirty days revealed:*On 3/23/18 and 3/26/18 she had physical and verbal behaviors. *On 3/26/18 she had social behaviors. Review of resident 37's behavior and other progress notes from her 8/18/17 admission through 3/27/18 revealed:*She was admitted from home and was pleasant and cooperative. -She was brought by her husband and was walking independently without an assistive device. *On 8/23/17 she was packing up clothes and wearing her roommates clothes. *On 8/25/17 an MDS note stated she was eager and friendly, but staff had reported she was rummaging through her roommates belongings and her clothes. *On 9/15/17 she was being moved to another room due to rummaging through items. - .Her new roommate will tolerate that behavior better . *On 10/5/17, CNA overheard this resident tell her roommate 'stop hitting me.' CNA was outside of room and did not witness this resident being hit. Resident states she did not get hurt, assessed and no injury noted. CNA redirected the roommate of this resident out of this area. *On 11/1/17, at pm meal this resident attempted to make her tablemate put his nasal cannula on, telling him that he had to and she knew so because she once worked here. When this nurse intervened to separate this resident and her tablemate this resident became very angry striking out at this nurse then grabbing my arm and trying to yank me around. This nurse to resident 'that's enough, take your hands off me and don't touch me like that, it's not acceptable.' Resident began to yell again that she can do what she wants because she once worked here. Tablemate removed and placed at a different table secondary to this resident would not calm down and quit yelling. This resident struck out at and grabbed this nurse 2 more times. Staff will continue to monitor. *On 11/7/17, At app. (approximately) 1015 this am, this resident was sitting in a chair, and approached by another resident. This resident started yelling at the other resident, telling her to sit down. The other resident did not sit down, so this resident then took her by the hand and physically sat her down in a chair. She then yelled 'I used to work here, and you stay there!' This resident was then educated on not touching others. She kept repeating 'but I used to work here, I was a CNA' I explained to her that she no longer works here, and cannot touch other residents. She then promised that she wouldn't do that again. *On 11/20/17, CNA informed this nurse that resident has been having behaviors of: wandering into other resident's rooms, attempting to help residents out bed (even resident that require extensive/dependent assist), taking items and clothing that do not belong to her. Refusing to change clothes even after wearing same clothes for days. CNA tells me that she become very angry and yells at them when they attempt to correct her and refuses to cooperate. When they attempt to take clothing or items from her and return them to their owner, she will yell and argue saying 'I won that, its mine.' Note left for Dr. (name) updating her. *On 12/17/17 a 8:55 p.m. noted, This nurse heard resident yelling at her roommate .This nurse told this resident that she needed to go back to her side of the room. Resident swung her arm at me and yelled that she was a CNA here and that she could do as she wished. I again told her to go to her side of the room and keep her hands to herself. Resident continued to yell and tried x4 to grab this nurse. Resident did eventually go to her bed and sit down but continued to yell out . *On 12/28/17 there were notes about her moving her roommate's things around in room. *On 12/31/17 she was yelling at her roommate on two different occasions that evening. *On 3/14/17 at 9:16 a.m. a social service (SS) note, SS called (name) (husband) to get verbal consent for behavior assessment ordered by Dr. (name). SS explained that Sharon hit bath aide and Dr. (name) sent order. His response was 'I don't think that is a good idea.' When SS asked him why not, he stated 'I don't want to pay for it.' SS stated that Medicare would cover part or all of it he consented. He also stated that 'hitting is typical for (resident name).' SS sent referral to (facility name) for behavior assessment. -That note occurred during the first week of survey after surveyors had been questioning referrals for other residents with behaviors. --There had been no mention of getting an evaluation prior to that. -That was the same day 3/14/18 a new antidepressant medication ([MEDICATION NAME]) was ordered, but it had not been mentioned in the notes. Review of resident 37's 3/27/18 care plan related to behaviors revealed:*Most interventions were initiated on admission. *Revisions were not done timely to reflect the above incidents and behaviors. *Behaviors specific to her roommate's concerns had not been addressed. 4. Observations, interviews, and record reviews during the surveyor related to resident 53 revealed:*His undated baseline care plan had not been individualized and specific related to his skin concerns. *His 3/13/18 care plan did not have any additional interventions added related to his newly acquired pressure ulcer. Refer to F686, finding 2. 5. Observations, interview, and record review during the survey related to resident 21 revealed her care plan had not been followed or updated related to her activities and grief. Refer to F740, finding 1. 6. Observations, interview, and record reviews during the survey related to resident 33 revealed her care plan had not been updated timely related to her falls and interventions for them. Refer to F610, finding 2. Surveyor: 7. Interview and record review on 03/13/18 at 11:06 a.m. with CNA supervisor I related to care plans revealed: *The CNAs used a cheat sheet as a reference for how to take care of the residents. *She was the one who updated those cheat sheets with input from the nurses. *CNAs also had access to review the resident care plan in the electronic medical record. *She agreed residents' care plans and cheat sheets should have been updated to their current status and needs. *Staff should have been following the resident's care plans. Interview on 3/14/18 at 1:21 p.m. with LPN A and RN G regarding residents' care plans revealed: *Residents' care plans should have been updated to reflect their current status and needs. *Care plans were typically only updated by the Minimum Data Set (MDS) coordinator nurse and the director of nursing (DON). *Nurses could have updated care plans, but most of the time they left that up to the MDS nurse. *Resident care plans should have been followed and updated as changes occurred. Interview on 3/14/18 at 3:05 p.m. with the administrator, DON, MD'S assessment coordinator, and social services coordinator S regarding care plans revealed: *Charge nurses usually did not update or revise residents' care plans. *Most changes and updates to the care plans were being done by the MD'S coordinator with the assistance of the DON. *They agreed residents' care plans should have been updated to reflect the resident's current status and needs. -Updates should have been done as changes occurred. *They expected residents' care plans to have been followed by staff. Review of the provider's revised (MONTH) 2010 Care Plans-Comprehensive policy revealed: *The individualized comprehensive care plan was to have included measurable objectives, and timetables to meet the resident's medical, nursing, mental, and psychological needs. *The comprehensive care plan was to have been based on a thorough assessment that had included but was not limited to the Minimum Data Set assessment. *Each resident's comprehensive care plan had been designed to: -Incorporate identified problem areas. -Incorporate risk factors that had been associated with identified problems. -Build on the resident's strengths. -Reflect the resident's expressed wishes for care and treatment goals. -Reflect treatment goals, timetables, and objectives in measurable outcomes. -Identify the professional services that were responsible for each element of care. -Aid in preventing or reducing declines in the resident's functional status and/or functional levels. -Enhance the optimal functioning of the resident by focusing on a rehabilitative program. -Reflect currently recognized standards of practice for problem areas and conditions. *Care plan interventions were to have been designed after consideration of the resident's problem areas and their causes. *Care plans were to have addressed underlying sources of the problem area. *Assessments of residents were to have been ongoing and care plans were to have been revised accordingly. *The care plan team had been responsible for the review and updating of the care plans at the time of: -Significant change in the resident's conditions. -When desired outcome was not met. -When the resident had been readmitted to the facility from a hospital stay. -Quarterly review. Review of the provider's revised (MONTH) 2006 Using the Care Plan policy revealed:*3. Cans are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved.*4. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or the MD'S Assessment Coordinator. Review of the provider's revised (MONTH) 2006 Care Plans - Preliminary Policy revealed: *1. To ensure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of admission.*2. The Interdisciplinary Team will review the Attending physician's orders [REDACTED]. dietary needs, medications, and routine treatments, etc.), and implement a nursing care plan to meet the resident's immediate care needs.", "filedate": "2020-09-01"}
{"rowid": 43, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 686, "scope_severity": "H", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure four of five sampled residents (21, 41, 47, and 53) who required staff assistance with care had not developed facility acquired pressure injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. *She was dependent on the staff to: -Anticipate her care needs. -Initiate and implement interventions to ensure her health and safety. *She developed facility acquired pressure injuries to both her heels on 2/19/18. -She also had skin concerns to both her great toes. Observation on 03/13/18 at 08:17 a.m. of resident 41 revealed: *She was laying in bed on her right side with her face covered with blankets. *She had one foam heel boot sitting on top of the covers. -It was not on her foot. Interview and record review on 03/13/18 at 10:09 a.m. with licensed practical nurse (LPN) D regarding resident 41 revealed he:*Was her charge nurse that day. *Was a traveling nurse and had been working there since 2/1/18. *Stated she had pressure injuries and treatments of: -Daily left heel and right heel pressure injury monitoring by the nurse. -A blister area to her right great toe. -[MEDICATION NAME] dressing to her left heel suspected deep tissue injury to be changed every three days as needed. -[MEDICATION NAME] dressing to her right heel suspected deep tissue injury to be changed every three days and as needed. *Stated he was already done with her treatments for the day. *Stated her [MEDICATION NAME] dressing changes were due to be changed on 3/14/18. -The surveyor requested to observe that dressing changed and he agreed stating he would be working again. Observation and interview on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during resident 41's personal care revealed:*The resident was out at activities in her wheelchair. *The CNA wheeled her into her room and assisted her to the bathroom. *The resident was wearing small slippers and compression stockings to both legs. *The surveyor questioned if the resident had any skin concerns and the CNA stated:-When the resident had come back from the hospital she was in bed and a lot more sleepy than she had been before. -She thought the resident had some pressure areas on her buttocks and a spot on the back of her head. -The resident also had a history of [REDACTED]. -She did not mention any pressure areas to her heels. *The CNA offered to remove the resident's compression stockings and slippers to view the resident's legs and feet. *Her skin had: -Some scratch marks on her shins. -Dark brown/black scab-like areas to the backs of both her heels. -A darkened spot on the tip of her left great toe. -A callus-like area on the tip of her right great toe. *The surveyor questioned if the nurses had done treatments to those heel and toe areas. -CNA stated she was not sure but there was nothing on them when she had gotten her up that morning for breakfast or the day before when she had given her a bath. *The CNA questioned if the resident should be wearing her compression stockings when she had those areas on her feet. -The surveyor questioned her back and asked how she would find out that information. -The CNA stated she would refer to her CNA cheat sheet. *Review of that undated CNA cheat sheet revealed: -No mention of skin concerns for her. -She should have been wearing a compression stocking to her left leg only. -There was no mention of heel boots or when to wear them. *The CNA stated she thought the resident only needed to wear the heel boots when she was in bed. During the above interview and observation at 03/13/18 11:13 a.m. LPN D arrived to the resident's room: *The surveyor: -Requested he come in to look at the resident's feet and legs. -Asked him about the [MEDICATION NAME] dressings he said had been in place that morning. *He stated he had done her treatments around 5:00 a.m. and he thought the dressings were there. -He stated she should have the foam dressings on her heels and the foam boots on at all times. *He then left the room saying he would be right back. Continued observation and interview on 03/13/18 at 11:17 a.m. in resident 41's room revealed: *Registered nurse (RN) [NAME] and LPN D arrived back to the room. *RN [NAME] stated she oversaw the pressure injuries in the building and did the weekly measurements on them. -She stated the residents heel pressure injuries started as purple spongy areas about three weeks prior. -She thought they were looking better. *When the surveyor questioned what was in place for pressure injury prevention RN [NAME] stated they: -Put an air mattress on her bed. -Started the foam boots at all times. -Initiated the [MEDICATION NAME] dressing changes. -Notified the dietary department. *She confirmed all those interventions had been implemented after the pressure injuries had developed. -Prior to that she had a regular pressure relieving mattress and repositioning every two hours like all residents. *She applied new [MEDICATION NAME] dressings to both heels. *When asked to stage or identify those areas currently she: -Said they were scab-like areas now. -Would not answer what stage they were currently. --She stated she would have to look them up but they started as deep tissue injuries. *RN [NAME] thought the resident should have been wearing heel boots at all times. -That was listed on the nurse treatment administration record (TAR) for them to check placement. *CNA I was still in the room and stated she thought the boots were just when the resident was in bed. *When asked about the resident's compression stockings she stated the resident probably should not have been wearing them but she was not sure. -CNA I confirmed the CNA cheat sheet said for the resident to wear the left leg stocking only. *All three staff confirmed there was a lack of communication and collaboration for the resident's intervention between what the nurse's expectations were and what the CNA expectations had been. *The CNA cheat sheet was again reviewed with the nurses and CNA and they confirmed there was no mention of the resident's pressure injuries or foam boots. Continued interview and record review with LPN D at the nurse's station regarding resident 41 revealed:*He confirmed the TAR had the nurses checking that the resident was wearing the foam boots at all times. -He agreed she had not been wearing the boots that morning. *Review of the resident's last signed 2/27/18 physician's orders [REDACTED]. -Place [NAME] hose (compression stocking) on left lower extremity was started on 1/20/18. -The [MEDICATION NAME] dressing changes to her left and right heel suspected deep tissue injuries were supposed to be checked every day and changed every three days and as needed. --Those treatments started on 2/20/18. *He confirmed her orders had not been followed for her foam boots, the [MEDICATION NAME] dressings, or the compression stockings. *He thought the resident may have removed the dressings herself but the CNAs should have known to contact the nurse to replace them. -If a dressing change was completed that should have been documented on the TAR for proof of the change. *Review of the resident's (MONTH) (YEAR) TAR entries: -The [MEDICATION NAME] daily and PRN entries were started on 2/20/18 and showed no indication of when the dressings were actually changed. --He confirmed that finding and stated there should have been a way to know when they were changed. -There was an entry to check bruise on Left great toe end for breakdown until resolved that was started on 1/22/18. -There was an entry to Monitor blister area Right great toe end. Check Q (every) day. every day shift for monitor that was started on 2/26/18. *Review of the resident's 3/13/18 care plan with LPN D revealed:-There was no mention of her order for the left compression stocking only. -Her care plan had not been followed for her foam boots or the dressings to her heels. *While reviewing the record and discussing that mornings interviews and observations this information confirmed the deficiency. Observation on 03/13/18 at 02:00 p.m. of resident 41 in the lobby area revealed she was not wearing the heel boots again. She was only wearing her small slippers. Observation on 03/13/18 at 03:06 p.m. of resident 41 being wheeled in her wheelchair by staff from the lobby area to the dining room revealed she was not wearing the heel boots. She was not wearing either compression stocking and had her small slippers on. Observation on 03/13/18 at 03:54 p.m. of resident 41 in her wheelchair in the hallway revealed: *She was propelling herself a little in the wheelchair. *The foam boots were on her feet. *Her mood appeared anxious and she was reaching for the boots. Observation on 03/14/18 at 01:10 p.m. of resident 41 revealed:*She was sitting on the edge of the bed in her room. *An unidentified staff member was charting on a kiosk in the hallway outside her room. *She had no foam heel boots on her feet. -She was not wearing socks or shoes. *The foam heel boots were sitting on the chair in the corner of her room. *She was attempting to peel off her left heel dressing. Observation and interview on 03/14/18 at 01:21 p.m. with LPN A and RN G during resident 41's dressing changes revealed:*LPN A was a traveling nurse and had been working in the facility for about one month. *RN G had been working in the facility for about one year. *They removed her previous dressings and applied new FoamLite dressings to both her heels. -It was unclear if a FoamLite dressing was the same thing as an [MEDICATION NAME] dressing. -[MEDICATION NAME] dressing was the product listed on her physician's orders [REDACTED]. *The surveyor asked the nurses about the current staging of her pressure injuries on her heels. -Neither would answer and stated they would have to look at her record. *RN G indicated the resident's pressure injuries occurred after she had a fall and broke her arm. -She had been in bed a lot more after that fall. *She liked to sleep on her back frequently. *RN G stated they did have staff repositioning her more frequently after she returned from the hospital but she was unsure if that would have been documented. *They thought her heel boots were only supposed to be on when she was in bed. -They were not aware they had been ordered for all times. *LPN A thought the resident was supposed to wear compression stocking to both her legs. -She was not aware it was only ordered for her left leg. *Both nurses thought the compression stockings should have been on hold due to her pressure injuries. *They agreed preventative interventions should have been in place prior to a resident getting pressure injuries. -Pressure relieving interventions should have been individualized based on the resident's need. *They confirmed her risk of skin breakdown increased when she had a change in her condition and had spent more time in bed than before. -Her pressure relieving interventions should have been changed related to her decline in condition prior to the development of facility acquire pressure injuries. *They stated RN [NAME] was the nurse who oversaw the pressure areas in the facility. -RN [NAME] did the skin assessments weekly for those areas. *The nurses should have done the daily monitoring of the pressure areas and documented that monitoring. *Both nurses confirmed there was no specific place they documented when the dressings were changed. -The nurses just put their initials in the TAR entries once per shift. -It would have been difficult to track when or if the dressings were changed with the current documentation on the TAR. Interview on 03/14/18 at 03:05 p.m. with the administrator, director of nursing (DON), Minimum Data Set (MDS) assessment coordinator, and social services coordinator S regarding resident 41 revealed: *They confirmed the resident had developed facility acquired pressure injuries. *All residents should have been repositioned every two hours and all the mattresses were pressure relieving. *They confirmed there was a lack of consistency and collaboration between the nurses and CNAs with the resident's pressure ulcer treatments and interventions. -There should have been better communication and collaboration. *They agreed her physician's orders [REDACTED]. *The resident had a decline in her condition overall which increased her risk of skin breakdown. *They agreed her pressure relieving interventions should have been re-evaluated and changed related to that change in condition. -That should have been done prior to the development of her pressure injuries. *During that interview the surveyor requested copies of her Braden assessments, wound assessments, and progress notes related to skin due to the lack of access to the resident's electronic medical record. -Refer to F867, finding 2. *The DON printed the Braden Scale for Predicting Pressure Sore Risk for the resident. -Review of those assessments indicated she was scored as: -Low risk on 8/1/17, 8/7/17, 8/8/17, 8/15/17, 8/22/17, 9/27/17, 10/4/17, 10/18/17, and 11/5/17. -High risk on 2/19/18, which was the day the pressure injuries were noted. -They confirmed the above information. Interview on 03/15/18 at 09:36 a.m. with physical therapy assistant C regarding resident 41 revealed:*She had worked in the facility for about four months. *The resident had not worked with therapy during that time frame. *After the resident broke her arm she was screened by therapy and not picked up for services. *She confirmed the resident had a decline in her condition from her previous level of function. Observation on 03/28/18 at 9:20 a.m. of resident 41 in her room revealed:*She was laying in bed on her back. *She was not wearing the foam heel boots. -They were sitting in the chair in the corner of her room. *Her physician's orders [REDACTED]. Review of resident 41's Pressure Ulcer PUSH Tools that were done weekly by RN [NAME] from 2/19/18 through 3/15/18 revealed: *The scores worsened from a two to four on her left heel and from a one to three on her the right heel. *There was no mention of her toe areas. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the PUSH Tools revealed: *She did not really look at or do anything with those PUSH scores. *She was directed to just do the PUSH Tool weekly. Review of the telephone physician's orders [REDACTED]. *On 2/19/18: -1. Foam boots on at all times to both feet. -2. [MEDICATION NAME] gentle to L heel suspected deep tissue ulcer (check) QD (everyday) (triangle sign for change) Q (every) 3 days/PRN (as needed) - resolved. -3. [MEDICATION NAME] gentle to R heel suspected deep tissue ulcer (check) QD (change) Q 3 days/PRN - resolved. --The order was written by RN [NAME] on 2/19/18 and was signed by the physician on 2/22/18. *On 2/26/18 monitor blister area to R great toe end (check) QD. -That was written by RN [NAME] and signed by the physician on 2/27/18. *There was no telephone order for the left great toe area. *A 3/13/18 telephone order was written for the foam boots to be on only when in bed after the surveyor had questioned staff about the boots. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the above telephone orders revealed: *She just wrote up the orders for the skin treatments when a new area was found. -Those orders were then sent to the doctor to be signed. *There was no specific skin guidelines or protocol for nursing to reference for what kind of treatment should have been started. *The [MEDICATION NAME] was one they used a lot and she thought it worked well. Review of resident 41's physician's progress notes from her admission on 8/1/17 through 3/15/18 revealed: *There was no mention of pressure injuries until the 2/27/18 note. That note stated: -She has developed some superficial pressure sores on both heels. - .Heel sores are covered with [MEDICATION NAME] border. --[MEDICATION NAME] which was the ordered treatment was not mentioned. Review of resident 41's last signed 2/27/18 physician's orders [REDACTED].*To Check bruise on left great toe end for breakdown until resolved every day shift. -Order was started on 1/22/18. *Daily pressure ulcer L heel monitoring under assessments tab until resolved every day shift.-Order was started on 2/20/18. *Daily pressure ulcer R heel monitoring under assessment tab until resolved every day shift. -Order was started on 2/20/18. *Foam boots at all times to both feet every shift for unstageable ulcer. -This is the first time the areas were listed as unstageable. --Other documentation listed them as suspected deep tissue injuries. -Order was started on 2/19/18. *[MEDICATION NAME] Gentle to Left heel suspected deep tissue ulcer. Check Q day, change Q 3 days/PRN till resolved as needed for wound care be sure to chart all dressing changes in PCC. -Order was started on 2/20/18 *[MEDICATION NAME] Gentle to Left heel suspected deep tissue ulcer. Check Q day, change Q 3 days/PRN till resolved every day shift for wound care be sure to chart all dressing changes in PCC. -Order was started on 2/20/18. *There were two entries for [MEDICATION NAME] for the right heel suspected deep tissue injury that were the same as the left. -Both orders were started on 2/20/18. *Place TED hose on left lower extremity every day shift for inflammation -Order was started on 1/20/18. *Regional Health Pressure Ulcer Pressure Ulcer Push tool (under assessments) R heel to be completed q Monday with skin assessment measurements every day shift every Mon for wound day. -Order was started on 2/20/18. -There was an identical entry for the left heel. *Skin care per facility protocol as needed. -Order was started on 11/5/17. *Weekly skin assessment to be completed on Mondays every day shift every Mon. -Order was started on 12/14/17. *There was no mention of any skin concerns to her back of her head, buttocks or right great toe. Review of resident 41's Skin Integrity Assessment Records from admission through 3/15/18 revealed: *There was no mention of pressure injuries until the 2/19/18 one which listed: -A suspected deep tissue injury to her right heel measuring 0.5 cm by 0.5 cm. -A suspected deep tissue injury to her left heel measuring 0.7 cm by 0.7 cm. -An other area to the back of her head measuring 5.5 cm by 5.5 cm that said monitor pink blanchi. -An other area measuring 1.0 cm by 8.0 cm that states both buttock and discolored pink area. -Further documentation for the left heel dark area description of: --non-blanching dark area with surrounding pink blanching tissue, foam boots applied. will have daily pressure ulcer charting and push score to be done q week on Monday. EHOB on bed. -Further documentation for the right heel ulcer of: --dark area surrounded by 0.7 by 0.8 white tissue that is not fluid filled or boggy. *On 2/26/18 listed: -The suspected deep tissue injury to her right heel measuring 0.7 cm by 0.7 cm. --That was larger than the week before. -The suspected deep tissue injury to her left heel measuring 1.0 cm by 0.7 cm. --That was larger than the week before. -The back of her head and both buttocks areas had no measurements. -Further documentation for the left heel was faint darker area on back of left heel. no bogginess noted. no drainage. [MEDICATION NAME] gentle with foam boots are on. -Further documentation for the right heel was faint dark area. no drainage. no bogginess. callous like area below. *On 3/5/18 listed: -The suspected deep tissue injury to her right heel measuring 0.8 cm by 1.0 cm. --That was larger in size again. -The suspected deep tissue injury to her left heel measuring 1.3 cm by 1.0 cm. --That was larger in size again. -The back of her head and both buttocks had no measurements. -Further documentation for the left heel was continues to be a dry tan scab like discolored area. will monitor. -Further documentation for the right heel was tan scab like area. no drainage. no bogginess. callous like area below that is 1.5 by 1.0. *On 3/21/18 listed: -The suspected deep tissue injury to her right heel measuring 0.5 cm by 0.7 cm. --That was slightly smaller. -The suspected deep tissue injury to her left heel measuring 1.2 cm by 1.0 cm. --That was slightly smaller. -There was no mention of the back of her head or buttocks areas. -Further documentation for the left heel was continues to be a dry brown scab like discolored area. will monitor. -Further documentation for the right heel was brown scab like area. no drainage. *There was no mention of areas of concern on her toes. Interview on 03/27/18 at 1:33 p.m. with RN [NAME] regarding the above Skin Intergrity Assessment Records revealed: *Those were her weekly wound assessments. *She did those weekly assessments on Mondays. *She confirmed the areas appeared to be getting large for the first two weeks after they were noted. *When asked about potentially changing treatments or notifying the physician she indicated they had no protocol of when that should have been done. -She thought the areas were getting better now though so the treatment was working. *When asked how she decided to stage them as suspected deep tissue injuries she stated it was because they appeared to be when they first were noted. -She stated they might have been unstageable areas now. -She thought if the scabs came off of them there would be nothing underneath. *She confirmed the toe areas had not been measured or assessed weekly and could have been pressure injuries. -She had put an order on the TAR for the nurses to monitor them daily. *She stated she usually focused on pressure injuries only during her weekly assessments. Review of resident 41's Pressure Ulcer/Stasis Ulcer Daily monitoring records from 2/19/18 through 3/15/18 revealed:*They were not completed daily. *Forms were completed only on the following dates: -2/19/18. -2/21/18. -2/22/18. -2/26/18. -3/5/18. -3/12/18. -3/14/18. *According to these forms the physician was only notified on 2/19/18 even though the measurements got larger for both heels. *There were no records for the areas on her toes. Interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding the above Pressure Ulcer/Stasis Ulcer Daily Monitoring forms revealed: *They should have been completed daily by the charge nurses. *She confirmed there had been several days that were not done. *She agreed they had not mentioned the areas on her toes. *The resident's TAR directed the nurse to complete these daily. -The nurses had signed on the TAR that these were getting done daily but the records proved otherwise. Review of resident 41's interdisciplinary progress notes from her admission on 8/1/17 through 3/15/18 related to her skin revealed: *On her admission on 8/1/17 there was no mention of pressure ulcers or her risk of skin breakdown. -The note stated .Skin has numerous bruises and [MEDICAL CONDITION] . *There were injuries related to falls to her skin from admission through 3/15/18 that included bruising, skin tears, or other lacerations. *On 1/22/18 Left great toe assessed and toe blanches with small bb sized spot of light dusky bruise noted at tip. No boggy tissue, vesicle or pressure area noted. Will monitor with daily check tx at this time. -Unsure if this was the same area as noted during the observation on 3/13/18. *On 1/24/18 resident was sent to hospital for ultrasound of left lower leg and found to have a [MEDICAL CONDITION]. *After her fall on 1/31/18 where she fractured her arm there were notes indicating she: -Was in bed or sleeping more than before. -Was not eating as well, was seeing speech therapy, and had diet order changes. -Had pain related to her fracture. *There was no mention of skin concerns until 2/19/18. *On 2/19/18: -The nurse note stated resident skin checked during bath upon assessment multiple skin discolorations were found on back of head, both heels, and couple areas on bilateral buttocks all were measured and recorded. new mattress in now in place, boots were applied and cream to the bottom was applied family was notified. -The dietitian note stated Resident noted as having unstageable areas to both heels. Intake at meals has been *On 2/20/18 the dietitian note stated The area is suspected deep tissue injury not open. Discontinue the [MEDICATION NAME] Extra. -There was no: --Note by nursing that day. --Indication of why the [MEDICATION NAME] supplement would not be recommended for a suspected deep tissue injury. *On 2/21/18: -At 12:46 p.m. a nurse note Dressings changed to heels and they were off. no drainage or open area noted on heels r/t suspected deep tissue wounds. See charting under assessments tab. -At 12:52 p.m. a nurse note Dressing changes to back of both heels this am as dressings off. No change in condition of wounds. Foam boots do not stay on feet well as resident moves feet back and forth. Will continue to tx. --Both those notes were by the RN E. *On 2/26/18 was the next note by the RN [NAME] and stated: -Informed per primary nurse to check (resident's) right great toe. Found blister/soft like area tan/brown in color that is 1.3 x 1.0 (1.3 centimeters by 1.0 centimeters) in size. Wears only slipper socks and foam boots and is on air bed. Will monitor at this time. Not staged as ulcer. Ulcers on right and left heel were measured today and documentation noted in skin integrity assessment. -There was no mention of a change in interventions related to that new skin concern. *On 3/5/18 by the RN [NAME] stated: -Right great toe previous vesicle is dry and no longer fluid filled. No dressing on toe. Has continued dry scab like areas on back of heels r/t previous purple boggy areas that are pressure related with no drainage. Dressings to heels changed. Back of head continues with same discolored blanching area and shows no regression. Buttocks are clear. -This was the first mention of the buttock areas since 2/19/18. *On 3/12/18 the RN [NAME] nurse stated wound care done to both heel ulcers and noted them to be dry and without change. Both have smaller brown scabs. No redness/drainage. *On 3/13/18 at 6:07 a.m. the charge nurse stated Resident laying in bed supine, eyes closed .Heel [MEDICATION NAME] and boots in place. Will continue to monitor. -There were no further notes from that nurse that day. -In the observations and interview above with that nurse the resident's foam boots and dressing had not been in place. *On 3/13/18 at 9:03 p.m. the nurse stated Resident removing boots, socks, and dressings to her feet. Staff attempts to reapply or distract unsuccessfully. -This was the only documentation related to the resident removing her own dressings and was after the surveyor had questioned the nurse about it. Review of resident 41's 3/14/18 care plan related to her skin revealed:*This was requested to be printed with all the revisions and edits to see the history of the interventions. *There was no mention of the areas of concerns to the back of the resident's head, her buttocks, or left great toe. *The only change in her interventions for skin from her fall on 1/31/18 through the development of her pressure injuries on 2/19/18 was to: -Ensure that the steri strips on my forehead remain clean dry and intact. Keep dressed/treated as prescribed. *After the pressure injuries to her heels were identified on 2/19/18 interventions were added for: -I have an EHOB (name brand) on my bed, I am to be repositioned q 2 hours and I wear foam boots at all times. -I will have dressing changes to my heel ulcers per orders with daily and weekly charting per orders until resolved. --According the above record review and observation the orders and daily charting orders were not followed. *She had another focus area related to her left leg [MEDICAL CONDITION]. -That had not mentioned her order to wear [NAME] hose to her left leg only. -During the observation on 3/13/18 she was wearing [NAME] hose to both legs and the physician's orders [REDACTED]. Continued interview on 03/27/18 at 01:33 p.m. with RN [NAME] regarding resident skin concerns revealed: *She did not want to be called the wound nurse she was just the nurse who did the weekly measurements on pressure injuries. *She confirmed the documentation for skin concerns and pressure injuries was incomplete and unclear. *She stated she had no formal training for pressure injuries other than a webinar after last year's survey. *She had been the nurse overseeing wounds during the previous recertification survey in (MONTH) of (YEAR). -She was aware of the concerns the survey had identified with pressure injuries at that time. *She agreed individualized pressure injury prevention interventions should be implemented prior to pressure injuries developing. *Residents' care plans should be updated with those interventions and followed by the staff. *physician's orders [REDACTED]. *The resident's physician's should have been updated: -On any new pressure injuries. -Periodically on existing pressure injuries if they worsened or were not improving. *The provider had general physician's standing orders that stated Skin care per facility protocol. -There was no specific guidelines for the nurse to implement a specific treatment. *She indicated the nurse would decide on a treatment, write the telephone order, and send that order for the physician to sign. 2. Observation on 03/12/18 at 05:17 p.m. of resident 53 revealed: *He was very thin with a small body frame. *His skin appeared thin and fragile. *He was sitting in high back wheelchair in his room with his eyes closed. -The wheelchair appeared to have a cushion in it but it was difficult to see with him sitting in it. *His bed had an air mattress on it. Review of the revised 3/12/18 facility resident matrix edited by the DON indicated resident 53 had been admitted with skin concerns. Review of resident 53's medical record revealed: *He was admitted on [DATE]. *He had short and long term memory problems. *His [DIAGNOSES REDACTED]. *Review of his hospital transfer record indicated he had skin concerns to both feet and legs. -[DIAGNOSES REDACTED]. *He was dependent on staff to: -Anticipate his care needs. -Assist with his activities of daily living. *His 2/15/18 admission physician's progress note indicated: -He had a history of [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 44, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 688, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (21) who had limited mobility had been screened and/or placed on a restorative program (RC) to maintain her range of motion (ROM) and physical abilities. Findings include: 1. Review of resident 21's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). *She had a Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. *What activities and meals she had participated in outside of her room was her choice. *She had: -Therapy services for strengthening upon admission to the facility. --Those services had been discontinued d/t (due to) the resident's refusal to participate. *No documentation to support the therapy services had referred her for a RC program to ensure her current mobility status was maintained. Observation and interview on 3/12/18 at 5:22 p.m. of resident 21 revealed: *She had appeared: -Very thin, weak, frail, and her hair was unkempt. -To be able to move her arms without difficulty, but no spontaneous movement of her legs was observed. *She had been: -Laying in her bed resting. -Awake and talked very little when spoken to. *The head of her bed had been elevated to approximately thirty-five degrees. *She had scooted down in the bed so her chin rested on her chest. *Her feet had been hanging over the foot board that was attached to the bed. Continued observation and interview on 3/12/18 at 5:34 p.m. with resident 21 revealed: *An unidentified staff member brought a tray in containing her supper. *The unidentified staff member: -Placed the supper tray on the bedside table and positioned it in front of the resident. -Rolled the head of her bed up further. -Had not: --Attempted to reposition the resident or asked the resident if she would like to be moved up higher in the bed. *The unidentified staff member left the room. *The resident made no response when the surveyor inquired if she was comfortable in that position. Observation and interview on 3/13/18 from 8:11 a.m. through 8:57 a.m. with resident 21 revealed: *She had: -Been laying in bed. -The same shirt on as the day before and her hair remained unkempt. -Been positioned higher up in the bed so her feet were not hanging over the foot board. -Been drinking a cup of coffee. *Her facial affect and appearance remained unchanged when spoken to. *She had not eaten breakfast yet and decided to remain in her bed for breakfast. *Certified nursing assistants (CNA) F and W assisted her with personal cares, changed her clothes, and positioned her up higher in the bed. -She refused to get out of her bed. Random observations on 3/13/18 from 9:10 a.m. through 5:15 p.m. of resident 21 revealed: *Her appearance and interactions with roommate and others remained minimal. *She was: -Out of her bed for approximately an hour the entire day. --That had been during dinner time. Review of resident 21's 1/15/18 quarterly Minimum Data Set (MDS) assessment regarding functional status and her range of motion revealed: *She had required extensive assistance from staff with bed mobility, transfers, moving around, dressing, toileting, and personal hygiene. *She used a wheelchair and had not been walking. *Her balance had been unsteady. *She had no limitation in her ROM at that time. Interview on 03/14/18 at 1:50 p.m. with physical therapy assistant (PTA) C regarding resident 21 revealed:*She used to receive skilled therapy services, but had frequently refused to work with them. *They had to discontinue those skilled services due to her lack of participation and not meeting the requirements for her to remain a part of skilled therapy services. *PTA C was not aware of the resident having been started or currently on a restorative program. -PTA C was unsure how those programs were set-up. *She thought the restorative program was overseen by certified nursing assistant (CNA) supervisor I. Interview on 03/14/18 at 1:55 p.m. with CNA supervisor I regarding resident 21 revealed: *She had agreed with her understanding of the restorative criteria the resident would have benefited and was appropriate for the RC program. -Passive and active range of motion would have benefited her. --It could have been done on a one-to-one basis for her. *She reviewed the residents who were currently on restorative programs and could not locate one for the resident. *She had not set-up the restorative programs since it was not in her scope of practice. -She was a CN[NAME] *The MDS coordinator nurse would have set-up the residents' RC programs. *She again agreed with her understanding the resident should have been on a program to ensure she maintained her current ROM status and abilities. Interview on 03/14/18 at 2:00 p.m. with the MDS coordinator regarding resident 21 revealed: *She confirmed the resident was not on a RC program and would have benefited from one. *She had the capability of setting up RC programs after she received a referral from the therapy department. *She was not able to find a referral from the therapy department to set-up a RC program for the resident. *The resident had been on skilled therapy services but frequently declined and so their services had been discontinued. Interview on 03/27/18 at 5:00 p.m. with the director of nursing regarding resident 21 and RC programs revealed: *She agreed the resident was appropriate for a RC program to ensure she had no decline in her current ROM or abilities. *The therapy department initiated the resident's RC programs for the nursing staff to start. -They could have changed the RC program after it was initiated from the therapists. *There had been no assessment or referral completed by the therapy department to start a RC program for the resident. -A referral from the therapy department was not written until 3/17/18 after the surveyor had requested a copy of the restorative screening form. Review of the provider's 7/20/06 Restorative Nursing Program policy revealed: *Policy statement: -Restorative nursing programs are utilized to promote residents ability to adapt and adjust to living as independently and safely as possible. -This concept actively focuses on achieving and maintaining physical, mental, and psychosocial functioning. *Guidelines: -Licensed therapist will assess the resident and determine the resident's restorative needs from a therapist perspective on admission, at the ned (need) of a formalized rehabilitation program, quarterly or with a change in resident's status or abilities. -The licensed therapist will then collaborate with the facility's Restorative Nurse for the development an appropriate restorative nursing program. Review of the provider's RAI Manual, MDS 3.0, Version 1.15, related to ADLs, pages G-2 through G-3 and G-36, revealed: *Health-related quality of life included: -Almost all nursing home residents need some physical assistance. In addition, most are at risk for further physical decline . -A wide range of physical, neurological, and psychological conditions and cognitive factors can adversely affect physical function. -As inactivity increases, complications such as pressure ulcers, falls, contractures, depression, and muscle wasting may occur. *Planning for care included: -For some residents, cognitive deficits can limit ability or willingness to initiate or participate in self-care or restrict understanding of the tasks required to complete ADLs. -Most residents are candidates for nursing-based rehabilitative care that focuses on maintaining and expanding self-involvement in ADLs. *The definition of functional limitation in range of motion was Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury.", "filedate": "2020-09-01"}
{"rowid": 45, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 689, "scope_severity": "J", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > [NAME] Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (17) who had verbal, physical, and sexually abusive behaviors had been adequately supervised to protect the other residents from harm. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment. *For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center. *For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed necessary (Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting process), including feedback from the Medical Director. *For staff education: -Immediate education will be completed with all staff prior to their next shift, which will include the review of the following policies: Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting Process. We will focus on identifying signs and symptoms of abuse, how to report, when to report and who to report to in order to address the potential for a similar situation in the future. Staff will be knowledgeable about protecting themselves and other residents in accordance with our policies. Education completion will be reported to the Administrator. *For Medical Director education: -The review of the admission process and following policies will occur with the Medical Director upon his return the week of 3/19: Abuse and Neglect; Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident abuse; Preventing Resident Abuse, Resident Rights; Resident Incidence/Variance Reporting process. On 03/27/18 at 11:45 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observations, interviews, and record reviews during the survey on 3/12/18 through 3/15/18 and 3/27/18 through 3/28/18 related to resident 17 and his verbal, physical, and sexually abusive behaviors revealed: *He was not appropriately supervised and monitored to protect the other residents and staff members health and safety. Refer to S550, findings 1, 2, and 3. Refer to S600, findings 1, 2, 3, 4, and 5. Review of the provider's 1992 Briggs Healthcare pamphlet in the admission folder regarding resident rights revealed: *As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights. *Exercise of rights: You have the right and freedom to exercise your rights as a resident of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion, or reprisal. *Resident Behavior and Facility Practices: -Abuse You have the right to be free from verbal, sexual, physical or mental abuse. -Staff treatment: --The facility must implement procedures that protect you from abuse, neglect or mistreatment. --In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. --All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. *Quality of life The facility must care for you in a manner and environment that enhances or promotes your quality of life. Review of the provider's 6/13/16 Safety and Supervision of Residents policy revealed: *Policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. *Resident supervision is a core component of the systems approach to safety. Review of the provider's 6/27/16 Abuse Investigations policy revealed: Policy statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the provider's 5/20/03 Resident-to-Resident Abuse policy revealed: *All forms of abuse, including resident-to-resident abuse, must be reported immediately to the nursing supervisor, the director of nursing services, and the administrator. *Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents must be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. *Should a resident be observed/accused of abusing another resident, our facility will implement any or all of the following actions: -Document in the resident's clinical record all interventions and their effectiveness. -Consult psychiatric services for assistance in assessing the resident and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. -Complete an incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record. -Transfer the resident if deemed by the interdisciplinary care planning team and medical director as being a danger to him/herself or to others for psychiatric evaluation. -Report incidents, findings, and corrective measures to appropriate agencies as outline in our facility's abuse reporting policy. B. Based on observation, interview, record review, and policy review, the provider failed to ensure two of four sampled residents (5 and 41) who had multiple falls had possible causes of their falls identified and appropriate interventions initiated and implemented to possibly prevent further falls: *From her admission on 8/1/17 through 3/15/18 resident 41 had seventeen falls. -Seven of those falls had injury. *From (MONTH) (YEAR) through 3/27/18 resident 5 had seven falls. -Three of those falls had injury. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. *She was dependent on the staff to: -Anticipate her care needs. -Initiate and implement interventions to ensure her safety was maintained from injury and harm. Review of resident 41's Regional Falls Risk Assessments from her admission through 3/15/18 revealed: *According to the provider's revised 6/13/16 Fall Prevention policy a score of ten or higher indicated a risk for falls. *On 8/1/17, 8/7/17, 2/19/18 her score was twenty-six points. *On 11/5/17 her score was twenty-eight points. *She was at risk for falls due to her: -History of falls. -Impaired cognition. -Impaired vision. -Need for assistance with toileting. -Impaired mobility and balance. -Advanced age. -Health conditions. -Medications. Observation on 03/12/18 at 04:38 p.m. of resident 41's room revealed: *She had a low bed with an air mattress on it. *There were repositioning bars on both sides of the bed. *There was a fall mat folded up and placed at the foot end of the bed. *She had a doll and teddy bear laying on top of the bed. *There was a four-wheeled walker in her room. Observations throughout the day on 3/13/18 from 7:30 a.m. through 6:30 p.m. of resident 41 revealed: *She was cognitively impaired and appeared to become more anxious later in the day. *She required assist of one to two staff with transfers and personal care. *She used a wheelchair for mobility. -She could propel the wheelchair herself or had staff assist her. *Her wheelchair had an anti-roll back device on the back. Observation on 03/13/18 at 08:19 a.m. of resident 41 in her room revealed: *She was in her bed sleeping. *The bed was low to the floor with a floor mat beside it. *She had repositioning bars on both sides of the head of the bed. *She had a mobility alarm on the bed, and the lights were low in the room. Observation and interview on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during resident 41's personal care revealed: *The resident had been out at activities in her wheelchair and was wheeled into the bathroom by the CN[NAME] -She was wearing slippers on her feet and compression stockings to both lower legs. *She required staff assistance with most of her activities of daily living (ADL) due to her impaired cognition and history of falls. *She fell frequently and usually got hurt when she had fallen. -Her injuries included skin tears, bruises, hitting her head, a shoulder dislocation, and recently a broken arm. *She had recently come back from the hospital after a fall where she had broken her arm. -After she had returned from the hospital she spent a lot more time in bed than she had done prior to her injury. *She had alarms to alert staff when she was trying to transfer herself. Observation and interview on 03/13/18 at 11:17 a.m. with registered nurse (RN) [NAME] and licensed practical nurse (LPN) D in the resident's room revealed:*She was supposed to wear her foam boots to both feet at all times for pressure relief related to pressure injuries on both of her heels. -An air mattress was also put on her low bed after those areas had been noted. *She required staff assistance with her ADLs due to her impaired cognition, immobility, and history of falls. Review of resident 41's interdisciplinary progress notes and incident reports including the investigations from her admission on 8/1/17 through 9/30/17 revealed: *At the time of her admission on 8/1/17: .Resident was living at an assisted living home and experienced several falls .Resident is a fall risk, so to have alarms on at all times. Can transfer with 1 assist and gait belt. Unsteady on her feet . *On 8/3/17 she had an unwitnessed fall between the office and the dining room and hit her head causing a cut to her left eyebrow. -The 8/3/17 progress note included: --Chair alarm was listed for alarms used and functioning properly. --Yes was listed for the care plan reviewed and updated. --Go to assisted dining room per family request was the suggested intervention. -An 8/7/17 note on the incident report included Fall meeting: Resident had a fall on 8/3/17 in dining room .She was carrying her dishes .Interventions to prevent future falls include pressure alarm to bed and w/c and moving resident to hall 300 dining room where she can be monitored closely. --According to the 8/1/17 note above the pressure alarm had already been in place prior to that fall. -An 8/14/17 progress note that was also on the incident report stated Fall meeting: Discussed resident's fall on 8/3/17. Resident continues to eat her meals in the 300 Hall dining room and reports being comfortable and happy there. Staff say that the resident turns off her pressure alarm and still gets up un-assisted to ambulate. Resident is pleasant, but very difficult to re-direct due to poor memory and does have reported episodes of 'sun-downing.' She cont. on therapy and cooperates well with them. Resident can ambulate w/ (with) assist and FWW (front-wheeled walker). --That note had not mentioned a change in interventions. *As of 8/9/17 there was minimal documentation related to transferring herself, behaviors, or delusions. *On 8/11/17 a progress note stated .needs to focus on walking, staff can now walk with her to meals, etc with hand hold assist, needs frequent frequent reminders to ask for assistance. Therapist is working on education for how safety alarm works and her responses to it . *On 8/12/17 a progress note stated .able to walk with standby assist for over 200 feet, working with resident to recognize sound of safety alarm and how to react . -It was unclear why the resident needed to know how to react to the alarms. --Unsure if the alarm would have been an appropriate intervention, because the resident was able to shut the alarm off. *On 8/15/17 she had an unwitnessed fall in the hallway near the vending machines. -The progress note for the fall included: --No was documented for her alarm use and function. --Yes was listed for care plan reviewed and updated. --Resident to have cane or 4 wheelwalker at all time was listed for a suggested intervention. ---That was not a new intervention. -Several days later there were notes on the incident report from fall meetings that included: --On 8/21/17 PT to eval if needs walker. Staff informed that she must have someone walk with her. and Fall Meeting: Discussed resident's falls on 8/3 and 8/15/17. Resident now has rolling wheeled walker. She still requires staff to walk with her. Resident turns her pressure alarms off. Continues to work with therapy. --On 8/28/17 .discussed resident's fall on 8/3/17 and 8/15/17. Resident continues to work with therapy. They have given her a 4WW (four-wheeled walker). Resident seems to enjoy using this b/c (because) she can set her 'baby' (a stuffed toy mouse named [NAME]) on the seat and push him around. Does have pressure alarm on bed and chair, she is not supposed to be up ad lib per therapy. However, resident turns her alarms off and frequently gets up w/o (without) assist. Very poor memory. --On 9/6/17 .Resident continues to get up un-assisted and walk w/o her FWW. Staff has to frequently go get her walker for her. Resident has very poor memory and requires on going supervision. -There was no mention of any new interventions other than the stuffed toy mouse. *From 8/15/17 through 9/12/17 progress notes indicated she continued to work with therapy, would transfer herself at times, and would forget her walker at times. *On 9/12/17 she had an unwitnessed fall in her room. -There was no mention of any new interventions in the incident report. -The progress note included: -No alarms for alarm use and functioning. -No response for the care plan being reviewed or updated. -Res. (resident) already with frequent checks and has continuous reminding to call for help was the suggested intervention. --That was not a new intervention. *It was unclear when the alarms were discontinued through review of the progress notes from 8/28/17 through 9/12/17. *On 9/25/17 she had an unwitnessed fall in her room, hit her head causing a laceration to her right forehead, and was sent by ambulance to the emergency room for evaluation. -Notes on the incident report on 9/27/17, 10/2/17, and 10/4/17 included: -- .CNA says that resident appears to become more agitated and impulsive towards the evenings. Note left for Dr. (name). Nurse encouraged to use her PRN [MEDICATION NAME] if other interventions are not successful. --The other interventions were not mentioned. -The progress note for the fall included: --N/A was documented related to her alarm use and function. --No was listed for care plan reviewed and updated. --None was listed for suggested interventions. *On 9/29/17 she had a witnessed fall by the door of the dining room while walking independently with her walker. -The incident report included a fall meeting note on 10/4/17 that stated .went over resident's falls. Risks, possible triggers, timing, resident's thoughts, etc. were discussed. The team feels that the resident's delusions are leading to her falls i.e. hearing voices, worried that she needs to go to work or that her family is looking for her. Staff have reported her behaviors escalate dramatically in the evenings. They have tried multiple interventions over several weeks including, but not limited to activities, food, drink, exercise, calling family, etc. Resident becomes inconsolable and very agitated. Dr. (name) placed resident on [MEDICATION NAME]. The team feels that this is in her best interest as her delusions cause her emotional distress and self injurious behavior. --That was the first note mentioning delusions or what interventions they had tried for her behaviors. -Progress note for the fall included: --N/A listed for alarm use and function. --No response for the review and updating of the care plan. --Continue to redirect her on the proper way to use walker was the suggested intervention. ---That was not a new intervention. Continued review of resident 41's interdisciplinary progress notes and incident reports including the investigations from 10/1/17 through 11/30/17 revealed: *On 10/6/17 she had an unwitnessed fall in her room and pulled a shelf down. -There was no mention of a new intervention in the incident report. -The progress note included: --Resident has no alarms, is ambulatory was listed for her alarm use and function. --No response was listed for reviewing and updating the care plan. --Remove resident's personal shelf from room & locate a more stable shelf for her items. was listed for suggested intervention. *On 10/10/17 she had a witnessed fall when attempting to walk without her walker. -The progress notes included: --N/A for the alarms. --No response for reviewing and updating the care plan. --Continue to try and redirect resident was the suggested intervention. -There were no new interventions implemented. *On 10/13/17 she had a near fall in the commons areas for staff outside of the dining room. -Continue to monitor her and attempt to redirect her to use her walker was the suggested intervention. -There were no new interventions implemented. *On 10/24/17 she had an unwitnessed fall in the dining room and dislocated her right shoulder/arm. She was sent by ambulance to the emergency room . -There was no intervention implemented promptly after the fall. -Notes on the incident report included: --Several days later on 10/30/17: Resident prior to fall was in the dining room per staff with a pink bucket (basin). This is not per interview with staff a Witnessed fall. Staff did administer PRN medications when resident became agitated and not redirectable in the most recent past. --Almost two months later on 1/17/18 Fall team met and discussed falls on 12/13/17, 12/17, 1/02/18, and 1/7/18. Resident is on Restorative program for ambulation and is working with therapy on improving toileting with verbal cues, hygiene and self feeding. Is on Q (every) 2 hour toileting, Q 2 hour resident checks. -The progress notes included: --N/A for reviewing and updating the care plan. --Unsure for a suggested intervention. *On 10/28/17 she was sent to the hospital for an upper respiratory infection and was admitted . -She returned to the facility on [DATE]. *On 11/7/17 she had a witnessed fall in the hallway near the dining room where she hit her head and left elbow. -The incident report had not mentioned any new interventions. -The progress notes stated: --Continue to monitor closely, reinforce requesting assistance for a suggested intervention. --No response was listed for reviewing and updating the care plan. *On 11/9/17 she had an unwitnessed fall in the hallway and received a skin tear. -The progress notes included: --Reviewed for care plan reviewed and updated. --Frequent reminders to not try to stand up by herself, constant monitoring as she is impulsive and has dementia for the suggested intervention. -There was no incident report or investigation for that fall. -There were no new interventions implemented. *On 11/13/17 a progress note stated SS, DON and Administrator met with (name) POA of (resident) to discuss increase of behaviors and need of 1:1 (one-to-one) care. Discussed placement in other facilities in Rapid City that have locked units that could be appropriate for (resident). (POA) was open to this possibility if behaviors continue to increase. Will monitor situation, Nursing will give (POA) a weekly call to update on behaviors. -No further notes were found about her being transferred to another facility. *On 11/30/17 a progress note stated Resident was found laying on top of the wood over the bathtub in her bathroom . -There was no incident report or investigation for that fall. -There were no new interventions implemented. Continued review of resident 41's interdisciplinary progress notes and incident reports including the investigations from 11/30/17 through 3/12/18 revealed: *On 12/13/17 she had a witnessed fall in the lobby and bumped her head. -A 1/17/18 note on the incident report over a month later, was the same note as the 10/24/17 fall. -Progress notes included frequent reminders, supervision by staff as the suggested intervention. -There were no new interventions implemented at the time of the fall. *On 12/28/17 she had an unwitnessed fall in her room. - resident laying on ground, next to bed, with gown off and brief pulled down, bed wet. CNA had last been in room [ROOM NUMBER] minutes prior, doing safety check, and at that time resident was asleep. Resident bed in low position, floor mat next to bed (under resident). -There was no mention of when she had last been assisted to the bathroom. -A 1/17/18 note on the incident report several weeks later was the same as the 10/24/17 fall. -The progress note included: --Gripper socks on feet when in bed as a suggested intervention. --Reviewed listed for the reviewing and updating of her care plan. *On 1/3/18 she had a witnessed fall sliding from her low bed onto her fall mat. -The 1/17/18 note on the incident several days later was the same as the 10/24/17 fall. -There were no new interventions implemented at the time of the fall. *On 1/7/18 she had an unwitnessed fall in her bathroom. -The description was Resident states 'I fell and hit my back here' pointing to the bathtub. Resident was sitting on toilet, pull up wet. -Ten days later on 1/17/18 the note on the incident report was the same as the 10/24/17 fall. -There was no response listed for a suggested intervention in her progress notes. -No was listed for the care plan being reviewed and revised. -There was no new intervention implemented. *On 1/31/18 she had an unwitnessed fall in the hall outside her room with injuries. - .resident laying on her left side with blood coming from her left eyebrow and mouth. ROM completed to all but resident's left arm secondary to resident yelling out in pain saying, 'don't touch it, it's broke.' Staff assist x 3 with gait belt to get resident to stand and place in a W/C . -She was sent to the emergency room by staff per facility van and returned later that day. -A 3/1/18 note on incident report over a month later stated Pressure alarm placed with family consent to alert staff of attempt to transfer without assist . -The progress notes from her return on 1/31/18 and through the night had not mentioned what injury had occurred. -A 2/1/18 progress note stated Resident seen and examined for an acute visit due to fall last evening with fracture to left elbow. Dr. (name) applied a posterior splint to the left arm . -There was no mention of new interventions implemented. -Review of the final Required Healthcare Facility Event Reporting form for the 1/31/18 event indicated: --Investigation is ongoing per DON. Resident returned from hospital on [DATE] @ 16:10 with dx (diagnosis) of fx (fracture) to L elbow .Staff per investigation, state she was sleeping in her bed only five minutes prior to her being found on floor .Facility and staff have tried every available option for decreasing her fall risk for example anti roll back on w/c, providing activity/diversion with any increased agitation that was not easily redirected. Primary provider and family discussion with nursing on 2/2 (2/2/18) and decision to initiate pressure alarm to alert staff of resident attempts to self transfer to decrease her risk of falls . -The action taken was other: Discussion with family and Physician on safety concerns. *For the above events there was no evidence to support a thorough investigation had occurred to support: -Staff had been interviewed to give details related to each event. -A root cause of the multiple falls had been or could have been determined. *For most of the above falls appropriate interventions had not been: -Implemented or documented timely. -Related to the possible cause of the fall to potentially prevent future falls. -Realistic due to her level of cognitive impairment. Review of resident 41's 3/14/18 care plan related to falls revealed: *That care plan was requested to be printed with all revisions and edits to show the history. *There was a focus aware of: -I wander and I am unaware of safety needs/my physical limitations resulting in falls. I also have a history of frequent falls, where I injure myself. 10/24/17 - fall with RUE (right upper extremity) dislocation. 1/31/18 - fall in 300 hall attempting to walk unassisted w/ (with) laceration to forehead and major injury to my left elbow. *Goals were: -I will not walk around without my assistive devices and your assist, to eliminate me having a fall. -I will incur no falls or injury through next review date. *Interventions were: -Assist me to toilet every 2 hours. --That was initiated on 1/19/18 and revised on 2/1/18. -Determine if physical needs may be making me restless. Am I hungry? Am I thirsty? Do I need to use the toilet? Am I having pain? --That was initiated on 11/14/17. -Do a fall risk periodically. No bed canes per therapy recommendations. Remind me to have a 'walking partner' as that is the phrase therapy uses. W/c (wheelchair) removed from my room so I do not push it and fall. --That was initiated on 8/16/17 and revised on 9/28/18. --That had not matched her current status of using a wheelchair, having repositioning bars on bed, and not walking the way she used to. -Ensure that I am wearing the splint on my left arm as prescribed. I do try to take it off frequently, wrapping it gently with ace wrap does help. Assess my pain frequently and offer PRN pain medication to keep me calm and comfortable. I am refusing to wear my splint. --Resident had no splint in place during the time of survey. It was unclear when it was discontinued by record review. -Ensure that my bed is in the low position with landing strip (fall mat) when I am napping/sleeping. --That was initiated 2/21/18 after her frequent falls and major injuries. --This was not followed during an observation on 3/28/18. -I am very unsteady, I do have to use my w/c more frequently as I cannot stand/walk w/o (without) my legs giving away. --That was initiated on 11/14/17. -I have anti-roll back bars on my w/c, as I do not understand my limitations and frequently attempt to stand/transfer w/o assistance from my w/c w/o locking the brakes. --That was initiated on 1/25/18 and after most of her falls had occurred. -If you notice that I am up walking unassisted, do not leave me alone, send another staff member to obtain my w/c. --That was initiated on 8/15/17 and revised on 2/19/18. -Keep my bed in low position with landing strip when I am napping/sleeping. --That was a duplicate entry with an initiated date of 2/19/18. -My family and leadership/nursing team here at the facility has decided that I would benefit from a personal pressure alarm. It is necessary for my safety/well being to prevent further falls. My personal alarm will enable me to obtain assistance when I need to get up, as I cannot remember to call for help due to my dementia and do not understand my physical limitation. This alarm does not have any restraining effects on me. --That was initiated on 2/2/18. --There was no mention of her having alarms on admission or when they had been discontinued prior to this. -Orient me to immediate surroundings. -Point out simple landmarks within the facility to me. -Provide me with emotional support for my feelings paired with calm factual information. (inquire where I am going, who I am looking for, why am I sad, anxious, etc.) --The above three interventions were initiated on 10/25/17. -Provide consistency in routine including physical exercise. Include me when possible with tasks, as I love to stay busy and perform household duties. --That was initiated on 10/25/17 and revised on 11/14/17. *It was not clear that interventions were initiated promptly related to her above fall dates. -The interventions frequently had not matched what the nurses stated they would implement in their progress notes or the fall team notes. Phone interview on 03/14/18 at 08:15 a.m. with resident 41's physician who was also the medical director revealed: *The resident had several falls and injuries related to her falls since she was admitted to the facility in (MONTH) (YEAR). *Several of her falls resulted in minor or major injuries including: -Hitting her head. -Bruises. -Skin tears. -Lacerations requiring steri-strips or stitches. -A shoulder dislocation. -A recent arm fracture. *He stated she had poor safety awareness. *Her cognitive impairment caused her to attempt to do things on her own that she should not have done. *He had assisted with changing her antipsychotic medication in hopes to lessen her anxiety and behaviors. *She had a history of [REDACTED]. *He agreed there should have been interventions implemented in an attempt to prevent potential falls and injuries. Observation and interview on 03/14/18 at 01:21 p.m. with LPN A and RN G in resident 41's room revealed: *They indicated the resident had a history of [REDACTED]. -She had gotten injured during some of those falls. *LPN A was a traveling nurse and had worked in the facility for about one month. *RN G had been working in the facility for about a year. *They stated when a resident fell or an incident occurred the nurse should have: -Assessed the resident. -Completed an incident report form. -Documented the incident in the progress notes. -Notified the resident's physician and representative. *Incident reports should have been filled out completely and accurately.<BR/", "filedate": "2020-09-01"}
{"rowid": 46, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 700, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "Based on observation, interview, and record review, the provider failed to ensure assessments had been followed for two of two sampled residents (41 and 53) who had repositioning bars on their beds. Findings include: 1. Observation of resident 41 on 03/13/18 at 08:19 a.m. revealed she was laying in her bed. There were repositioning bars on both sides near the head of her bed. Review of resident 41's medical record revealed: *Her 3/13/18 care plan had no mention of repositioning bars. *Her 8/1/17 Bed Cane (Repositioning Bar) Assessment indicated: -She had none on her bed. -At this time, bed canes are not recommended for Pt (patient/resident) due to Pt is able to complete bed mobility (rolling side to side, scooting in bed) with no assistance. Pt is able to get out of bed with assistance without using a bed cane. *Her 2/19/18 Repositioning Bar Assessment Screen indicated:-The therapy assessment had not been completed. -The nursing assessment stated she would not use repositioning bars. -The section for notifying maintenance was not filled out. 2. Observation on 03/13/18 at 04:19 p.m. of resident 53 during personal care revealed:*He was laying in his bed. -There were repositioning bars on both sides near the head of his bed. *Certified nursing assistants assisted him with bed mobility and using a total mechanical lift to move him from his bed to his wheelchair. -During the observation he made no attempt to use the repositioning bars to assist with his bed mobility. Review of resident 53's medical record revealed:*His 2/16/18 baseline care plan and 3/13/18 comprehensive care plan had no mention of repositioning bars. *His 3/6/18 Repositioning Bar Assessment/Screen indicated:-The therapy assessment recommended repositioning bars. -The nursing assessment stated he would not use repositioning bars. -On 3/6/18 at 1:00 p.m. maintenance was notified by work order. Interview on 03/15/18 at 08:44 a.m. with licensed practical nurse A regarding resident 53 revealed:*She thought he might use the repositioning bars to assist with his bed mobility at times. *She agreed his assessment stated he should not have repositioning bars, and that had not been followed. Interview on 03/15/18 at 09:27 a.m. with physical therapy assistant C regarding resident 53 revealed: *His repositioning bars would have been appropriate according to therapy, but if nursing did not agree they should not have been on his bed. *His assessment should have been followed. 3. Interview on 03/15/18 at 09:45 a.m. with the plant operations supervisor regarding resident repositioning bars and the above residents revealed:*When maintenance staff were notified of any repositioning bars that needed to be put on or removed from a resident's bed they would complete that as soon as possible. *Work orders for repositioning bars were a priority item. *He stated work orders were submitted electronically. *He was unsure if they had received work orders to remove the repositioning bars from residents 41 or 53's beds. -He indicated he would look for those work orders and make a copy for the surveyor to review. -Those copies were not received by the end of survey on 3/28/18. Interview on 03/27/18 at 3:40 p.m. with the director of nursing and director of nursing support person B regarding the above resident's assessments and repositioning bars revealed: *Therapy and nursing both participated in the repositioning bar assessments. *If therapy and nursing did not agree they would have followed the nursing assessment. *Residents 41 and 53 should not have had repositioning bars on their beds. -Their assessments had not been followed. *Maintenance staff were informed through work orders to either put on or remove repositioning bars from residents' beds after the assessments were completed. -The surveyor again asked for documentation to support work orders had been done and was not provided those prior to the end of the survey on 3/28/18.", "filedate": "2020-09-01"}
{"rowid": 47, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 740, "scope_severity": "G", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the provider failed to ensure four of six sampled residents (17, 21, 42, and 58) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Observations, interviews, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 17 revealed his mental health had been unstable with inappropriate behaviors exhibited towards other residents and staff. Those behaviors had created the potential for mental and physical harm towards them and himself. Refer to F550 and F600. 2. Review of resident 21's 11/18/17 revised care plan revealed: *Focus area: I have specific activity preferences. -Goal for that focus area: My activity preferences will be honored when ever possible during my stay in this facility with current interventions through the next review date. -Interventions for that focus area: --Activity staff will provide me with tools to knit or crochet. It is one of my favorite activities. --I enjoy listening to a variety of country music. Invite me to participate in musical activities. --I enjoy reading. I have a subscription to Readers Digest. I will need my glasses when I choose to read. --I have a TV in my room and enjoy the following programs: Wheel of Fortune, Jeopardy, and Dancing with the Stars. --My religion of choice is Catholic. Remind me when rosary is taking place. *She had a focus area regarding her depression and mood. -That focus area did not support: --Her tendency to self-isolate. --The loss of her two children to ensure staff support through her grieving process had occurred. --Her history and involvement with grief counseling prior to her admission. *The staff had not implemented her care plan to support: -Her activity preferences and requests. -A focus area for her grief over the loss of her children. -Interventions for the staff to follow, so they could help the resident manage her loss of those children. Observation and interview on 3/12/18 at 5:22 p.m. of resident 21 revealed: *She had appeared: -Very thin, weak, frail, and her hair was unkempt. -To be able to move her arms without difficulty, but no spontaneous movement of her legs was observed. *She had been: -Laying in her bed best resting. -Awake and talked very little when spoken to. *She had responded with short yes/no answers and closed her eyes frequently. -Her facial expressions remained flat. *At times she had opened her eyes and just stared towards the bathroom door. *The head of her bed had been elevated to approximately thirty-five degrees. *She had scooted down in the bed, so her chin rested on her chest. *Her feet had been hanging over the foot board that was attached to the bed. *There had been a few family pictures on a bulletin board hanging on one of the walls. *She had a small TV that was placed on top of a bedside stand to her right and against the wall. -Other items on the bedside table were a cell phone and Ipad. -All of those items were not within her reach. *There had been no other: -Personal pictures or wall hangings on the other walls located in her area. -Personal items observed in her area. *The TV was not on, and the room was very quiet. *There was a bedside table next to her bed with drinks and a remote control for the TV on it. *She had resided in a shared room. *The divider curtain was opened, so she could look out the window. -That window curtain had only been partially opened. *Her roommate had been sitting in her recliner right next to the divider curtain. -There was no conversation witnessed between the two. *The room was not well lit. Continued observation and interview on 3/12/18 at 5:34 p.m. with resident 21 revealed: *An unidentified staff member brought a tray in containing her supper. *There had been various nutritional items on her tray including sealed containers of juice and yogurt. *The unidentified staff member: -Placed the supper tray on the bedside table and positioned it in front of the resident. -Rolled the head of her bed up further. -Had not: --Attempted to reposition the resident nor asked the resident if she would like to be moved up higher in the bed. --Asked the resident if she wanted the lids on the juice and yogurt containers removed. *The unidentified staff member left the room. *The resident made no response when the surveyor inquired if she was comfortable in that position. *The surveyor asked the resident if she could open the juice and yogurt containers on her own. -The resident stated If I can't open it I will call the staff. *She had shook her head no when asked if she went out to the dining room for supper. Interview on 3/12/18 at 5:49 p.m. with the DON regarding resident 21 confirmed the resident had stayed in bed for most of the meals. She stated, She maybe will get up for lunch. Observation and interview on 3/13/18 from 8:11 a.m. through 8:57 a.m. with resident 21 revealed: *She had: -Been laying in bed. -The same shirt on as the day before, and her hair remained unkempt. -Been positioned higher up in the bed, so her feet were not hanging over the foot board. -Been drinking a cup of coffee. *Her facial affect and appearance remained unchanged when spoken to. *She had not eaten breakfast yet and decided to remain in her bed for that meal. *Her room remained quiet and unchanged from the day before. *Certified nursing assistants (CNA) F and W assisted her with personal care, changed her clothes, and positioned her up higher in the bed. -She refused to get out of her bed. *The activities coordinator stopped in quickly and asked if she would like to attend the resident group meeting. -She declined. *Prior to leaving the room the CNAs and activities coordinator had not: -Made sure her phone and Ipad were moved, so they would have been within her reach. -Offered to turn on her TV or play some music for her. Random observations on 3/13/18 from 9:10 a.m. through 5:15 p.m. of resident 21 revealed: *Her appearance and interactions with her roommate and others remained minimal. *She was: -Out of her bed for approximately an hour the entire day. --That had been during dinner time. -Not observed reading, crocheting, watching TV, listening to music, using her Ipad, or visiting on her phone. *Her cell phone and Ipad always remained out of her reach. *No staff had been observed offering to: -Visit with her between personal care. -Make her room more pleasant and mentally stimulating. -Assist her with moving and stretching her legs and arms. -Assist her with any of the mentally, visual, tactile, and audio stimulating items documented above in her care plan. Interview on 3/13/18 at 5:15 p.m. with resident 21 revealed: *She confirmed: -What activities she participated in and how she spent her day was her choice. -The interventions listed in her care plan for activities were enjoyable to her. -The only staff who had visited with her that day was the CNAs. --That visitation had occurred while they had assisted her with ADLs. -This surveyor had been the only person to stop and visit with her that day. *When asked if: -She would like to use her cell phone and Ipad she had shook her head no. --She stated I didn't ask for them and I don't need it. -She would like to watch TV she shook her head no. -She wished others had stopped and visited with her, she got tears in her eyes and stated Yes. Review of resident 21's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). *She had a Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. *She had two children who had passed away within the last two years. *What activities she had participated in outside of her room was her choice. *She had: -Occasional panic attacks when any shortness-of-breath episodes would have occurred. -Recent medication changes to help with her mood and appetite. -Therapy services for strengthening upon admission to the facility. --Those services had been discontinued d/t (due to) the resident's refusal to participate. *On 1/25/18 she had: -Attended the care conference meeting to review her health and any other concerns she might have with the interdisciplinary department team (IDT). -Said she was very depressed and would like to visit with a counselor to help her handle the grief from the passing of her son. *No documentation to support: -An order and referral for grief counseling had been received until 2/1/18. --That order had been obtained per family request and occurred seven days after her own request. -On 1/30/18 and 2/13/18 the staff had informed the physician during those visits of her and the family's request for grief counseling. -The physician had been notified of that request until 3/20/18. --The physician had completed another ordered for the resident to continue with grief counseling. --That order was not obtained until seven days after the surveyor had completed interviews with the staff regarding that request and fifty-five days after her initial request. -The resident had received any type of grief counseling after her request on 1/25/18 until 3/23/18. Review of resident 21's nursing progress notes from 1/25/18 through 3/20/18 revealed: *No documentation to support: -The resident had requested to visit with a counselor regarding the loss of her son. -The physician had been notified of that request until 3/20/18. That had been fifty-five days after her initial request to receive grief counseling. -The resident had been referred to a grief counselor or a priest for mental health support during that time frame. -What action the administrative staff and IDT had done to ensure the resident received some type of grief counseling prior to 3/20/18. -The social service department had been actively involved to ensure the resident had received those services. *On 3/23/18 there was documentation to support (psychologist's name) would have been visiting with the resident on Thursday or Friday of that week. Interview on 3/13/18 at 5:26 p.m. with the activities coordinator regarding resident 21 revealed she: *Confirmed the resident had [MEDICAL CONDITION] and was having difficulties dealing with the loss of her son. *Had not considered putting the resident on a one-to-one list for the staff to see due to: -The resident was: --Capable of making choices on her own and attended those activities of her choice. --Not on end-of-life care. --Her family visited often, and those visits had been included as part of her activities. *Had not: -Considered assessing her room for adequate stimulation. -Recognized the resident was at risk for self-isolating and could have benefited from those one-to-one visits. *She confirmed: -The care plan supported the resident's activity preferences. -The staff had not ensured those interventions had been implemented for the resident on a regular basis and should have. *Agreed they should have been more aware of the resident's activity needs. Interview on 3/14/18 at 8:07 a.m. with the social services coordinator (SSC) S and DON regarding resident 21 revealed: *They confirmed the resident had a tendency to self-isolate and was having difficulties dealing with the loss of her children. *They had been aware: -She had requested to see a grief counselor. -Of the orders for her to receive grief counseling. *They agreed she would have benefited from those services. *The DON was to have followed-up with that request made by the resident on 1/25/18. -She was not sure where they were with that process. *They confirmed the resident had not received any type of mental health support since her admission and request on 1/25/18. Interview on 3/14/18 at 8:45 a.m. with the medical director revealed he had: *Been the resident's primary physician. *Confirmed her record review and the recent loss of children in her family. *Been aware of the order and request for her to seek grief counseling. -He had not followed-up on that request and was unsure as to where they were in that process. Interview on 3/15/18 at 8:15 a.m. with SSC S and the DON confirmed the activities coordinators interview. They agreed the resident had a tendency to self-isolate and would have benefited from staff one-to-one visits. They had no policy on one-to-one visits, as it was considered an intervention. They agreed the care plan should have identified the resident's recent loss of her children with interventions to help support her through that grieving process. Observation and interview on 3/27/18 at 12:35 p.m. with resident 21 revealed: *She remembered the state surveyor from two weeks ago and was excited to see her. *She was: -Laying in bed visiting with her roommate. -Well positioned and had pillows under each arm for further support. *The window curtain was pulled all the way back to allow for better viewing of the outdoors. -The room was very bright and provided a cheerful atmosphere. *The TV was on and was playing country music. *Her bulletin board had been covered with a pretty fabric allowing for a better view of the family photos. *Her Ipad and cell phone had been placed on her bedside table for easy access. *She: -Was well groomed, smiling, and very talkative. -Visited freely about her family that had included her son and mother. -Confirmed the difficulties she was having with the worsening of her depression after her son passed away. -Had been active with grief counseling groups and helping others battling with depression like herself prior to her admission. -Had believed in that process and the importance of what it offered to ensure her healing had occurred mentally. *A gentleman had been in last week to visit with her, and she appreciated it very much. -She stated It was very helpful. *She confirmed: -Her request for grief counseling some time ago. -Her and her family were not made aware of why there had been a delay in providing those services. -Her religion was very important to her, and no one had offered the support of a priest to visit with. -Visiting with a priest would have also helped her depression and healing. -She still continued to make her own choices about going out to meals and which activities she attended. Interview on 3/27/18 at 4:45 p.m. with the DON regarding resident 21 revealed she: *Confirmed: There had been a breakdown in communication and with the process to ensure the resident had received some type of mental health support. -They had not considered having a priest visit with her and should have. *Stated Honestly the process got broken, I did not go back and see what happened and should have. *Was not clear on the entire process to ensure that had occurred for the resident. *Agreed the social service department should have been more involved with mental health concerns for all the residents to ensure follow-through had occurred. *Confirmed the psychologist was in the facility on 3/22/18 to assess and visit with the resident. *Agreed: -There should have been clearer documentation in the medical record to support that visit. -The care plan should have been updated to support a grieving concern. *A policy for behavioral services and mental health had been requested and was not received upon exit from the facility on 3/28/18. Interview on 3/28/18 at 8:05 a.m. with the SSC S regarding resident 21 revealed she: *Confirmed there had been a communication breakdown with the process in making sure the resident received some type of counseling services. *Had not been a part of that process for a few months now. *Was not sure what had caused the change. *Agreed: -As a SSC and resident representative she should have been involved with all the residents and their mental health concerns as delineated in her job description. -She should have had the opportunity to facilitate for the residents and families when mental health concerns and behavioral concerns. -As a SSC her role was vital in ensuring: --Those services were carried through for the mental health well-being of the residents. --The families of those residents were comfortable and kept informed of what is put in place for their loved one. *Stated Currently the HUK (Health Unit Coordinator) will schedule any appointments for counseling services after she has received that order. I have no idea what happens after she receives that order. *Had been involved in completing assessments, monitoring, and documenting on the residents' behaviors. -That process had changed when the changes took place with administration. -Had not been sure why that change had occurred. -Agreed as a SSC reviewing behaviors and monitoring them had been a vital role of hers in the past but had not questioned the change. Interview on 3/28/18 at 12:46 p.m. with the health unit coordinator revealed she: *Confirmed the process the SSC had described in her interview. *Had worked part-time on Monday, Tuesday, and Wednesday. *Had not been aware of any order and request from the family for resident 21 to have grief counseling. -That order had been received on one of her days off. -She had not seen that order. *Reviewed the order in the chart to confirm the DON had written the order, and the charge nurse that day had initialed it. -The charge nurse had notified the family regarding the order. *Stated: -The nurse has the option to schedule the appointments or leave her a copy of the order and I'll take care of it when I return to work. -I have no idea what the nurse did with that order, I never got a copy of it. *Would have confirmed the order with the SSC and physician prior to making an appointment for the resident. -She stated I can't make the determination on who they see. *Would have contacted the families after she made an appointment for the residents. *Confirmed there had been mental health services available for the residents with referrals made. *Stated (Psychologists name) is available and his wife is a counselor. They come to the facility to see the residents. Interview on 3/28/18 at 3:45 p.m. with the administrator revealed he agreed the SSC S played a vital role in the process and advocacy for the residents with mental health concerns and should have been involved. 3. Observation on 3/13/18 at 8:51 a.m. of resident 58 with CNAs F and W during personal care and a transfer revealed: *He had been awake and laying in his bed. *He was very crabby and short tempered with the CNAs while they had assisted him. *They were patient and had explained all the processes involved with the care he required assistance with. *He had continually referred to everything they attempted to assist him with as rules. -He stated There are rules for everything, even wearing shoes in bed. Review of resident 58's medical record revealed: *An admission date of [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Required assistance from the staff to assist him with all ADL. -Been working with therapy department for strengthening, memory recall, swallowing concerns, and mobility. *On 3/13/18 the physician had written an order for [REDACTED]. -The charge nurse working that day had written and noted the order. *He had a BIMS Score of fourteen indicating he had good memory recall and was interviewable. Review of resident 58's nursing progress notes from 2/21/18 through 3/13/18 revealed: *On 3/13/18 at 1:16 p.m. the SSC S had documented: SS spoke with daughter today about reports of (resident 58's name) telling therapies and staff about wanting a gun so he could shoot himself. Daughter states that he is seeing his pastor weekly and had talked honestly about suicide. SS will forward information to nursing to request order for psychologist visit. *No documentation to support: -He had voiced any suicidal ideation's until 3/13/18. -The staff had initiated any type of process or procedure for those [MEDICAL CONDITION]. -A suicidal assessment had been completed on the resident to determine his level of mental instability and if there were concerns for his safety. *No documentation to support the psychologist had been in the facility to see the resident. Review of resident 58's initial and comprehensive 3/2/18 care plan revealed no focus areas with interventions to support a desire to end his life until 3/13/18. Interview on 3/14/18 at 8:50 a.m. with the medical director regarding resident 58 and his [MEDICAL CONDITION] revealed he: *Had been the resident's primary physician. *Had not been surprised about the [MEDICAL CONDITION] voiced by the resident. *Stated With the general population of the residents in the nursing home that have dementia and depression would expect this to happen. *Would have expected the provider to have: -A policy in place or some type of guidelines to follow. -Notified the resident's primary physician. -Them to have some type of monitoring process in place for those situations. On 3/14/18 at 8:00 a.m. the DON had been asked for their policy on residents with [MEDICAL CONDITION] at the times below: *At 8:30 a.m. the surveyor was provided with a policy for the hospital. *At 9:35 a.m. they had given the surveyor a piece of paper with no date or signature on it. -That piece of paper had CRSC Suicidal Ideation Process and Procedure typed on it with steps for the staff to follow in case a resident voiced suicidal thoughts. Interview on 3/14/18 at 9:46 a.m. with the DON revealed: *They had no policy or procedure in place for [MEDICAL CONDITION]. *The MDS assessment coordinator had given the above procedure to her and said that was the facility's protocol. *She confirmed that protocol had not been officially approved by the administrative staff. *She would have expected the staff to have placed any resident who voiced suicidal thoughts on fifteen minute checks. -That statement had been repeated several times. Interview on 3/14/18 at 2:13 p.m. with the DON and MDS assessment coordinator revealed: *On 3/13/18 was the first time they had knowledge resident 58 had of a history suicidal thoughts. *They agreed that type of information should have been available to them upon admission. *The psychologist had been in the facility yesterday to assess and visit with the resident. -They agreed there should have been documentation in his medical record to support that visit. *They were not aware there was no documentation to support the resident had been monitored for [MEDICAL CONDITION]. *Would have expected the staff to initiate one-to-one monitoring to ensure his safety. *The procedure above had not been available for the staff use. *The DON stated I didn't even know we had that, I'm sure the staff don't know we have it either and they should. Interview with resident 58 was attempted multiple times on 3/14/18 from 9:50 a.m. through 3:30 p.m. The resident had been either sleeping, out for a meal, or working with the therapy department. He had refused to visit for long periods at a time with the surveyor and would state repeatedly There are a lot of rules here, I'm hard of hearing, did you need something? Interview on 3/14/18 at 4:15 p.m. with the administrator, DON, MDS assessment coordinator, SSC S regarding resident 58 revealed: *They became aware of the resident's [MEDICAL CONDITION] in a care conference with him and his family on 3/8/18. -That had not been documented. -They agreed they should have documented and followed-up on those comments and concerns and had not. *The SSC S had received an email on 3/12/18 from the therapy department supervisor stating the resident continued to talk about wanting to die, and asking the staff to bring him a gun so he could shoot himself. *The MDS assessment coordinator had been working that day and completed an assessment of the resident to identify any risk of harm. -That assessment had been visual with no documentation found in the medical record to support any type of suicidal or harm risk assessment had been completed. -She stated I used to work with these types of people and he did not appear to be at risk of suicide. -She agreed that assessment should have been documented. *A copy of the therapist's notes had been requested for review. *They had: -Been working with the physicians to support a behavioral resource and service for them to utilize. --That process had been taking a long time d/t the lack of understanding from the physicians and their support to utilize them as a resource. -Access to two psychologists for support and one would have been able to come directly to the facility. --Those services required a referral from the resident's primary physician. -Been aware of the need for those behavioral services in the facility. Interview on 3/15/18 at 8:25 a.m. with licensed practical nurse A regarding resident 58 revealed: *She had been aware he had made comments about wanting to kill himself. -The other nurses had been aware of those comments also. -They had not reported it to the administration. *She stated: -His family said he says it all the time, and that its more out of annoyance. -He will say get me a gun and shoot me when we get him out of bed and when his family is here. *His comments had been sporadic and not daily. *She confirmed they had never charted on his behaviors and voicing wanting to kill himself. -She agreed they probably should have. *They had monitored and documented on him per his usual status. *She stated We are supposed to report these types of comments and situations to the SSC S but we haven't. *She agreed they probably should have to ensure there had been further investigation and assessment for his safety. *She had not been aware of any specific policy or protocol they were to have followed. Interview on 3/15/18 at 9:20 a.m. with the director of rehabilitation revealed: *She had: -Been in the process of locating resident 58's therapy documentation. -Confirmed he had made comments of wanting to go home and shoot himself during his therapy sessions. --Those comments had been sporadic and not daily. *The certified occupational therapist aide had stepped up during the interview and stated He had mentioned to us about bringing in a gun here too, so he could do it here. -That comment had happened last week. Review of the 3/12/18 at 2:05 p.m. email sent to the SSC S from the director of rehabilitation revealed: I want to let you know that (resident 58's name) continues to talk about wanting to die, that he wants to go home and kill himself, asks for a specific gun for someone to bring so he can shoot himself. Can we adjust or start an antidepressant? Can he see someone with (behavioral services name)? Any other suggestions? Review of resident 58's 3/13/18 therapy progress note entered by the physical therapist aide revealed: Pt (resident) continues to make comments about wanting to go home and shoot himself. or how he wishes he'd have another stroke so he can just die. Social Worker and Staff and family are aware of these suicidal thoughts and comments. Interview on 3/15/18 at 11:00 a.m. with the DON revealed: *She: -Had not been aware the staff nurses knew he had [MEDICAL CONDITION]. -Would have expected them to document on it and refer those concerns to the administrative staff. -Would have expected some type of monitoring to have occurred. -Would have expected the staff to have taken his comments seriously to ensure his safety and well-being. -Stated We can do fifteen minute checks, ect. On 3/15/18 at time the surveyor's left the facility there had not been any monitoring for [MEDICAL CONDITION] put in place for resident 58. Interview on 3/27/18 at 1:00 p.m. with CNA F regarding resident 58 revealed she: *Had been aware of his statements regarding suicidal ideation's. *Stated: -He does voice suicidal thoughts of 'just shoot' me when we help to the bathroom and stuff. -It's more in general, I don't think it's in a serious way. -We are to watch him for these comments and behaviors. *Was to have reported those comments of suicidal ideation to the charge nurse. Follow-up interview on 3/27/18 at 11:12 a.m. with the physical therapy assistant and certified occupational therapy assistant regarding resident 58 revealed they: *Confirmed he made sporadic comments of wanting to be dead and wanting to go home to kill himself. *Had been doing a co-treatment with him on 3/13/18 when they had reported his comments, to the nursing department. -The PTA had charted his comments, and the COTA informed the nursing department. *Were not aware of what the nursing department had done after it was reported, but his behaviors had improved. Interview on 3/27/18 at 5:25 p.m. with the DON regarding resident 58 revealed she:*Agreed the nursing department had not taken his comments of suicidal ideation as serious as the therapy department had. -She would have expected them to. *Confirmed there was a lack of documentation by all staff in his medical record to: -Support his history of suicidal comments. -Support the staff had done everything possible to ensure his mental health well-being had been assessed appropriately for safety. *Agreed SSC S should have been more involved with all the residents who had concerns of mental health instability and behavioral concerns. *Had not been able to identify when that process of SSC S involvement with those concerns had changed. Interview on 3/28/18 at 9:25 a.m. with the MDS assessment coordinator confirmed she: *Had been responsible to review and complete the behavioral documentation on all the residents' MDS assessments. -The process had been that way since she became the MDS assessment coordinator. *She had not recognized a concern with that and the SSC S not having as much involvement in that area. *Stated Everywhere else that I have worked the SSC would have been responsible for the behavioral monitoring, assessments, and documentation for the residents. *Had reviewed that concern and process with the SSC S. -The SSC S had been okay with the current process. Review of resident 58's 2/28/18 admission MDS section D revealed: *SSC S had completed his interview in that section to determine his mood and depression level. *Letter I.: Thoughts that you would be better off dead, or of hurting yourself someway. *The resident had responded yes with those thoughts occurring nearly everyday. Review of resident 58's 3/2/18 progress note documented by the SSC S revealed: *She had: -Completed a narrative from his admission MDS assessment. -Documented he had mild depression, no [MEDICAL CONDITION], and his BIMS score was fifteen. *There had been no documentation to support his interview above regarding thoughts of better off being dead. Review of resident 58's 3/8/18 care conference summary revealed: *His daughter had attended the meeting. *There had been no documentation to support the resident had a history of [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 48, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 745, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and job description review, the provider failed to ensure appropriate social services involvement for six of eight residents (17, 21, 42, 49, 53, and 58) who had mental health concerns to potentially maintain their psychosocial well-being. Findings include: 1. Observation, interview, and review of residents 17, 21, 42, 49, 53, and 58's medical records during the survey revealed a lack of social services involvement related to concerns with abusive situations, incidents and investigations, behaviors, grief support, and suicidal ideation follow-up. Refer to F550, F600, F609, F610, F740, and F758. Interview on 3/27/18 at 5:25 p.m. with the director of nursing (DON) and DON support person B regarding social services revealed she: *Agreed social services coordinator (SSC) S should have been more involved with all the residents who had concerns of mental health instability and behavioral concerns. *Had not been able to identify when SSC S involvement regarding those concerns had changed. *Had not specified what her expectations from SSC S were. *Stated: -Honestly the process just got broken for them. -I did not go back and check to make sure everything was in place for them as I should have. -I learned of the concerns through SS. Interview on 3/28/18 at 8:05 a.m. with the SSC S revealed she: *Agreed: -As a SSC and resident representative she should have been involved with all the residents and their mental health concerns as delineated in her job description. -She should have had the opportunity to facilitate for the residents and families for mental health and behavioral concerns. -As a SSC her role is vital in ensuring: --Those services are carried through for the mental health well-being of the residents. --The families of those residents are comfortable and kept informed of what is in place for their loved one. *Had been involved in completing assessments, monitoring, and documenting on the residents' behaviors. -That process had changed when the changes took place with administration. -Unsure why that change had occurred. *Agreed as a SSC reviewing behaviors and monitoring them had been a vital role of in the past but she had not questioned the change. Interview on 3/28/18 at 9:25 a.m. with the Minimum Data Set (MDS) assessment coordinator confirmed she: *Had been responsible to review and complete the behavioral documentation on all the residents' MDS assessments. -The process had been that way since she became the MDS assessment coordinator. *She had not recognized a concern with the SSC S not having as much involvement in that area. *Stated Everywhere else that I have worked the SSC would have been responsible for the behavioral monitoring, assessments, and documentation for the residents. *Had reviewed that concern and process with the SSC S. -The SSC S had been okay with the current process. Interview on 3/28/18 at 3:45 p.m. with the administrator revealed he agreed the SSC S played a vital role in the process and advocacy for the residents with mental health concerns and should have been involved. Review of the interviews above with the administrative staff revealed they all agreed: *The SSC S had been considered an advocate for the residents and should have been more involved with the residents' behavioral and mental health stability monitoring. -That process had recently changed. Those changes occurred at the time of the administrative staff changes. -No one had been able to confirm or support why the process had changed. *There had been a break-down of communication and follow-through with the assessment process of the above residents. -That process had been to ensure the residents' mental health issues were addressed timely. -That process could have created a potential concern to ensure the safety and mental health well-being of those residents had been met. Review of the provider's 3/2/15 Social Services Guidelines policy revealed: *Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practible physical, mental, or psychosocial well-being. *The social services personnel is responsible for: -Consultation to allied professional health personnel regarding provisions for the social and emotional needs of the resident family. -Assistance in meeting the social and emotional needs of residents. -Medically related social services are provided to maintain or improve each resident's ability to control everyday physical, mental, and psychosocial needs. These services may include, but are not limited to: --Maintaining contact with family to report on changes in health. --Assisting staff to inform residents and those they designate about the resident's health status and healthcare choices and their ramifications. --Providing or arranging provision of needed counseling services. --Through the assessment and and care planning process, identifying and seeking ways to support residents' individual needs and preferences, customary routines, concerns, and choices. --Finding options that most meet the physical and emotional needs of each resident. --Providing alternatives to drug therapy or restraints by understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet. --Meeting the needs of residents who are grieving. --Finding options, which most meet their physical and emotional needs. *The social services department is responsible for: -Identifying individual social and emotional needs. -Assisting in providing corrective action for the resident's needs by developing and maintaining individualized social needs. -Compiling and maintaining up-to-date information about community health and service agencies available for resident referrals. -Maintaining appropriate documentation of referrals and providing social service data summaries of such agencies. -Maintaining contact with the resident's family members involving them in the resident's total plan of care. -Working with individuals and groups in developing supportive services for residents according to their individual needs and interests. -Participating in interdisciplinary staff conferences, providing social service information to ensure treatment of [REDACTED]. Review of the provider's revised 3/19/18 Director of Long Term Care job description for the director of nursing revealed: .The individual must demonstrate knowledge of the principle of growth and development over the life span and possess the ability to assess data reflective or the resident's status and interpret the appropriate information needed to identify each resident's requirement relative to his/her age-specific needs. The Director of Nursing is responsible for hiring and disciplinary needs within the department to include supervision of other department directors. Review of the provider's revised 12/8/17 Senior Director Long Term Care Services job description for the administrator revealed:* .The Senior Director is responsible and accountable to ensure that action plans are set in place to reach goals the organization should successfully attain for its strategy to succeed. He/she must deploy the resources and develop goals to ensure employees understand the intent of the Strategic Plan/Operational Plan. *Develops a cohesive team as demonstrated by opinion survey, department survey results, exit interview, retention strategies, operational measurements and performance measurements developed by the department .", "filedate": "2020-09-01"}
{"rowid": 49, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 758, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, policy review, and manufacturers' instructions review, the provider failed to ensure one of five sampled residents (42) who had been given [MEDICATION NAME] (anti-anxiety) and [MEDICATION NAME] (anti-psychotic) on several occasions had documentation to support those [MEDICAL CONDITION] medications had been administered appropriately. Findings include: 1. Observation on 3/12/18 at 4:30 p.m. during the initial tour of resident 42 revealed: *He had a cut over his right eye with steri-strips and bruising. *He had multiple bruises, small scabbed areas, and skin tears on both arms. *Both hands had small open areas. *He was in a wheelchair and mumbled his words when spoken to. Review of resident 42's undated social services assessment by social services coordinator (SSC) S revealed: *He was cognitively impaired. *Behaviors were none known. *He was able to communicate his needs. Review of resident 42's medical record revealed: *He was admitted on [DATE]. *He was not orientated to person, place, or time. *He had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia. -[MEDICAL CONDITION] associated with current urinary tract infection. --He had improved mental status with antibiotic therapy and fluid hydration. -Weakness. *He lived at home with his wife prior and was no longer able to be cared for at home. *He had a [MEDICATION NAME] due to his history of [MEDICAL CONDITION]. *On 2/28/18 the consultant pharmacist had recommended a follow-up Abnormal Involuntary Movement Scale (AIMS) test due to all the [MEDICAL CONDITION] medications that had been initiated and discontinued since his admission. Review of a letter from his wife dated 2/4/18 to the staff at the nursing home revealed: *She said her husband would see things at home, but it was children playing or trains going by. *He was afraid to go outside, because he would get beat up. *He would carry the sugar bowl around looking for a girl that wanted sugar. *After a few days in the hospital with a urinary tract infection he became combative. -After the infection was under control he returned to his docile personality. *He enjoyed his stuffed kitty and liked root beer floats. Review of resident 42's nursing progress notes, medication administration records, and incident reports from his 2/7/18 admission through 3/4/18 revealed: *On 2/7/18 his physician had ordered [MEDICATION NAME] 1 milligram (mg) injection for anxious mood, behavior, anxiety, and agitation. -He had received that on 2/7/18, 2/14/18, 2/15/18, 2/20/18, 2/21/18, and 3/1/18. *On 2/8/18 his physician had ordered [MEDICATION NAME] (anti-psychotic) 100 mg twice daily; that had been discontinued on 2/16/18. *On 2/8/18 his physician had ordered [MEDICATION NAME] (anti-depressant) 225 mg daily; that was discontinued 3/13/18. *On 2/13/18 and 2/14/18 the physician had ordered [MEDICATION NAME] (anti-psychotic) 20 mg injection daily for mood and behavior. *On 2/14/18 his physician had ordered [MEDICATION NAME] 1 mg tablets for anxiety, which he was given nine times between 2/15/15 and 2/28/18. *On 2/15/18 he had a one-time dose of [MEDICATION NAME] 10 mg injection for agitation. *On 2/19/18 his physician had ordered [MEDICATION NAME] 5 mg injection twice daily for [MEDICAL CONDITION] and agitation; that was given twelve times and discontinued on 2/22/18. -It was ordered to hold if excessive sedation. *On 2/22/18 his physician had initiated [MEDICATION NAME] solution 50 mg injection to be given every twenty-eight days. *On 2/27/18: No abnormal behaviors demonstrated. *There was no note for 2/28/18. *On 3/1/18 at 1:50 a.m.: No abnormal behaviors. *On 3/1/18 at 1:53 p.m. he received an [MEDICATION NAME] 1 mg tablet. -There was no information addressing why that dose was given. *On 3/2/18 at 2:00 a.m. he had an unwitnessed fall in his room and complained of hip pain. -He was alert and his mental status was orientated to person only. -He had been sent to the emergency room for evaluation and returned at 6:29 a.m. to the facility. --The incident report was incomplete and that had no been reported to the South Dakota Department of Health (SD DOH). *On 3/2/18 at 11:09 p.m. he had received [MEDICATION NAME] 1 mg tablet. -There were no notes to indicate why it was given. *On 3/3/18: -At 1:27 p.m. a note stated he became irritated, but he was redirected with a root beer float. -At 5:42 p.m. he had received [MEDICATION NAME] 1 mg tablet. --There was no note indicating why it was given. --A note at 5:49 p.m. stated he was laying with his eyes closed. *On 3/4/18: -At 2:23 a.m. and at 8:32 a.m. he had received [MEDICATION NAME] 1 mg tablet. --There were no notes specific to those administrations. -At 9:48 a.m. he was agitated and attempting to stand up and ambulate from his wheelchair. He was hitting staff's chair and kicking walls. He was calling out Harry. -At 3:53 p.m. he was sitting on the side of his bed repeatedly yelling out names and taking off his clothes. -At 10:08 p.m. he was given [MEDICATION NAME] 1 mg tablet; --There were no notes indicating what his behavior was at that time. *He had no falls from his admission on 2/8/18 until almost a month later on 3/2/18. -That was after several [MEDICAL CONDITION] medications had been added or changed. Continued review of resident 42's nursing progress notes, medication administration records, and incident reports from 3/5/18 through 3/23/18 revealed: *On 3/5/18 at 6:01 p.m. he was given [MEDICATION NAME] 1 mg tablet; no behaviors were noted. *On 3/6/18 at 3:03 a.m. and 4:12 p.m. he was given [MEDICATION NAME] 1 mg tablet; no behaviors were noted. *On 3/7/18: -At 5:10 p.m. he had an unwitnessed fall in his room. --There was no incident report or investigation into that fall -At 10:49 p.m. he had been given [MEDICATION NAME] 1 mg tablet. --The note stated no abnormal behaviors. *On 3/8/18 at 7:56 p.m. he had received [MEDICATION NAME] 1 mg tablet. -The note stated no abnormal behaviors. *On 3/10/18 at 11:53 a.m. he had received [MEDICATION NAME] 1 mg tablet. -There was no note indicating why he was given the medication. *On 3/10/18: -At 1:30 p.m. he had a fall with no injury. --There was no nursing note, incident report, or investigation for that fall. --An event notification was sent to his physician addressing his fall. -At 7:45 p.m. he had another fall with no injury. --There was no incident report or investigation. --An event notification was sent to his physician about the fall. -At 10:07 p.m. he was given [MEDICATION NAME] 1 mg tablet; no notes indicated his behaviors. -At 11:15 p.m. the nursing notes indicated he had a fall. --The incomplete incident report stated the fall was unwitnessed in his room and he had no injuries. --It had been noted that [MEDICATION NAME] and Tylenol had been given before the fall. *On 3/11/18 -At 9:05 a.m. he had been given [MEDICATION NAME] 1 mg tablet for restlessness and agitation. --He was active in the hallways, sometimes wheeling his chair backwards. --He had been yelling Mom and yelling at his stuffed animals. --He hallucinates and grabs at the air according to the notes at 9:17 a.m. -At 9:31 a.m. he had a fall in his room and was incontinent of bowel. --There was no incident report or investigation. -At 10:15 a.m. he had another unwitnessed fall in the lobby with bruising on his legs. --The incident report and investigation had been incomplete. --An event notification was sent to his physician for a fall with no injury. -At 5:21 p.m. he had been given [MEDICATION NAME] 1 mg tablet. --The notes stated he had been active and wheeling around and walked in the hallways. He was reaching in the air for things. His facial expression was a frown. -At 10:15 p.m. he had another unwitnessed fall in his room with no injuries. --The incident report and investigation were incomplete. *On 3/12/18: -At 12:10 a.m. he had an unwitnessed fall with no injuries. --The incident report and investigation were incomplete. -At 8:12 a.m. he had been given [MEDICATION NAME] 1 mg tablet. --There were no notes indicating why it was given. -At 9:30 a.m. he had an unwitnessed fall and got a skin tear on his right hand. --The incident report and investigation were incomplete. -Two other skin tears were discovered with his bath later from that fall. -At 3:39 p.m. he had been given [MEDICATION NAME] 1 mg tablet. -At 5:58 p.m. he had another unwitnessed fall in his room and received a gash to his right eyebrow. --He was sent to the emergency room for evaluation and returned to the facility later with steri-strips to the area. --There was no incident report or investigation for that fall -At 11:28 p.m. he had been given [MEDICATION NAME] 1 mg tablet. --There were no notes indicating why it was given. *On 3/13/18 at 10:50 p.m. he had been given [MEDICATION NAME] 1 mg injection earlier for trying to get up, spitting at staff and pulling off dressings per nursing notes. *Review of the above documentation indicated he had nine falls within three days. -One of those falls resulted in an emergency room evaluation and others included minor injuries. Interview and record review on 3/14/18 at 2:45 p.m. with the director of nursing revealed: *On 3/2/18 and 3/12/18 when he was sent to the emergency room for evaluation related to fall those should have been reported to the SD DOH. *He had a [DIAGNOSES REDACTED]. -He had not had a psychiatric consult, but she thought he would benefit from it. *Discussion related to his his falls and notes from the daily leadership stand-up meetings revealed: -On 3/12/18 he had four falls and was given a busy board. -On 3/16/18 he had a fall after attempting to walk. --They would check on walking activities and a possible restorative plan. -On 3/21/18 they would have him seen for his sore hand and would talk to his wife about putting a pressure alarm on his bed and chair. -On 3/22/18 he now had a bed and chair alarm. -On 3/23/18 maintenance staff were to put on a anti-rollback device on his wheel chair. *They had not considered looking at the medications and comparing when the falls had happened. *They had not done any root-cause analysis for his falls. *He had been ambulatory at admission and had been able to carry on a conversation. Interview on 3/28/18 at 9:45 a.m. and again at 11:43 a.m. with registered nurse X concerning resident 42 revealed: *The [MEDICATION NAME] had helped him a lot, he doesn't try to stand up like he used to. *He used to be more talkative. *His behaviors had decreased overall since his [MEDICATION NAME] injections were started. *His behaviors included striking out at staff, grabbing in the air, and yelling. *He was now more sedentary, but he had more falls. *He could say full sentences occasionally, but he had talked more the first month he was here. *He did not walk independently now, but he was able to the first month he was there. *When he tried to stand up and walk that was when he fell . *Staff were to be with him at all times, at least with-in close distance. *She thought the [MEDICATION NAME] protected him from hurting himself when he started yelling and trying to get up. Review of the provider's 1/10/15 Administering Medication policy revealed: *If a dosage was believed to be inappropriate or excessive for a resident the person preparing or administering the medication should have reported it to the nurse. *After medication administration the individual administering the medication was required to record any results achieved, and when those results were observed. *If a resident used a PRN (as needed) medication frequently the attending physician and interdisciplinary care team with the support of the consultant pharmacist as needed, should have reevaluated the situation, examine the individual as needed, determine if there was a clinical reason for the frequency. Review of the last revised (MONTH) 2014 Pfizer manufacturer's instructions for [MEDICATION NAME] taken from the Internet on 4/10/18 revealed: *Indications and clinical use included [MEDICATION NAME] ([MEDICATION NAME]) is useful for the short-term relief of manifestations of excessive anxiety in patients with anxiety neurosis. *Warnings included: -[MEDICATION NAME] ([MEDICATION NAME]) is not recommended for the use in depressive neurosis or in psychotic reactions. -Since [MEDICATION NAME] has a central nervous system (CNS) depressant effect, patients should be advised against the simultaneous use of other CNS depressant drugs. -Excessive sedation has been observed with [MEDICATION NAME] at standard therapeutic doses. Therefore patients on [MEDICATION NAME] should be warned against engaging in hazardous activities requiring mental alertness and motor coordination . - .Impairment of performance may persist for greater intervals because of extremes of age, concomitant use of other drugs, stress of surgery or the general condition of the patient. *Precautions included: -Use in the Elderly: Elderly and debilitated patients, or those with [MEDICAL CONDITION], have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated with very low initial doses in these patients, depending on the response of the patient, in order to avoid over sedation or neurological impairment. -For elderly and debilitated patients reduce the initial dose by approximately 50% and adjust the dosage as needed and tolerated. -Use in Mental and Emotional Disorders: [MEDICATION NAME] (lorazepem) is not recommended for the treatment of [REDACTED]. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patients suspected of having psychotic tendencies.", "filedate": "2020-09-01"}
{"rowid": 50, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 842, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure 12 of 13 sampled residents (3, 5, 17, 21, 33, 41, 42, 47, 49, 53, 57, and 58) had complete documentation in their medical records. *Have residents' medical records readily accessible during the survey in a timely manner. Findings include: 1. Review of resident 3's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after four identified falls. Refer to F610, finding 1. 2. Review of resident 5's medical record revealed incomplete or missing documentation related to:*Her falls and interventions implemented related to them. Refer to F610, finding 8. Refer to F689, finding 2 under base statement B. 3. Review of resident 17's medical record revealed incomplete or missing documentation related to: *His behaviors and follow-up to them. Refer to F550, findings 1 and 3. Refer to F600, findings 1, 5, and 7. Refer to F609, finding 4. Refer to F610, finding 6. 4. Review of resident 21's medical record revealed incomplete or missing documentation related to: *Her mental health and grief. Refer to F740, finding 2. 5. Review of resident 33's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 2. Refer to F657, finding 5. 6. Review of resident 41's medical record revealed incomplete or missing documentation related to: *Details surrounding her multiple falls and interventions. *Her pressure injuries. Refer to F610, finding 10. Refer to F686, finding 1. Refer to F689, finding 1 under base statement B. 7. Review of resident 42's medical record revealed incomplete or missing documentation related to: *His behaviors and the reason [MEDICAL CONDITION] medications had been given. *Details surrounding his falls and investigations into them. Refer to F610, finding 13. Refer to F758, finding 1. 8. Review of resident 47's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 3. 9. Review of resident 49's medical record revealed incomplete or missing documentation related to: *Follow up and her status after an incident where she was inappropriately touched by another resident. Refer to F550, finding 2. Refer to F600, finding 2 and 3. 10. Review of resident 53's medical record revealed incomplete or missing documentation related to: *Him being verbally abused by his roommate. *His room change and notification to his representative about that room change. *His pressure injuries. *Investigations into his fall and unknown injuries. Refer to F600, finding 5. Refer to F610, finding 11. Refer to F686, finding 2. 11. Review of resident 57's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 4. 12. Review of resident 58's medical record revealed incomplete or missing documentation related to: *His suicidal thoughts and the follow-up response to them. Refer to F740, finding 3. 13. Review of the provider's (MONTH) (YEAR) Nursing Process and Documentation policy revealed:*H .The patient's response to the nursing care provided and the outcomes of the care are documented in the computerized documentation system.*I. Documentation is done using the current computerized documentation system unless system is down then paper charting needs to be completed.-1. Documentation is the responsibility of the nurse assigned to the patient (resident) each shift and must be objective data entered unless there are subjective resident concerns. -3. The Health Unit Clerk, LPN, or Nursing Assistant, under the supervision of the RN, may record data in the computerized documentation system. Review of the provider's revised (MONTH) 2013 Change in a Resident's Condition of Status policy revealed: *Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. *6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Interviews on 3/12/18 through 3/15/18 throughout the survey with the administrator and director of nursing (DON) revealed: *During the entrance conference on 3/12/18 at 4:30 p.m. the administrator was given a copy of the Entrance Conference sheet. -That sheet indicated the surveyors required access to the residents' electronic medical records (EMR) by the end of the first day of survey. -He was aware the surveyors needed access. *Within the first half hour of survey the DON brought each surveyor a sheet to obtain access to the EMR. -She stated she would send those forms to the information technology (IT) staff and get the access. -She was aware the surveyors needed to be able to readily access any residents' EMRs for review. On day two of the survey (3/13/18) the surveyors attempted to access the EMR with the login in information provided from the DON: *One surveyor was able to log in with their own computer. -Due to a network error once the surveyor logged in to the EMR it would only be open for a minute or two and then go back to the login screen. *The other four surveyors had problems getting logged into the EMR. *The DON and administrator had brought in laptops for the surveyors to use, but the logins did not work. *By the end of day two surveyors had not had access yet to the EMR. *Upon exiting the building at 6:45 p.m. that day the administrator was aware of the lack of access. -He would figure it out, and it would be ready for the next day. On day three of the survey (3/14/18) IT staff spent time with the surveyors for a large part of the morning getting them access to the EMR: *Laptops were brought in for the surveyors to use, but they had to be logged into by facility staff to get to the home screen. *If the surveyors left the laptop logged in with no movement for more than five to ten minutes it automatically logged off. -They would then have to find a facility staff person to log them in again. *The lack of access and problems with being logged out significantly interfered with the survey process and investigations. *The DON and administrator were updated on 3/12/18, 3/13/18, and 3/14/18 of the need for access. -They were aware it was interfering and slowing down the survey. -They verbalized understanding and were trying to work through the concern with the corporate staff. -Printed copies of parts of residents' medical records were requested due to the limited access to the EMRs. Review of the provider's revised (MONTH) (YEAR) Access to Regional Health Information Systems policy revealed:* .Information systems access authorization may be granted to an individual, or to a class of individuals, either on a case-by-case basis, or by policy.*There was no information relating to the timeliness of access to the medical records.", "filedate": "2020-09-01"}
{"rowid": 51, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-03-28", "deficiency_tag": 867, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "CZRE11", "inspection_text": "Based on interview and plan review, the provider failed to ensure an effective quality assurance performance improvement (QAPI) program had been implemented and followed through to develop and implement corrective actions for all residents. Findings include: 1. Interview on 03/28/18 at 1:30 p.m. with the administrator, Minimum Data Set (MDS) assessment coordinator, and registered nurse (RN) [NAME] revealed: *They tried to have monthly QAPI meetings. *The committee included the leadership team. *The medical director attended at least quarterly. *They used various methods and information to select actions of the QAPI committee: -Past surveys. -CASPER and quality measure (QM) reports. -They always reviewed certain things such as infection control, falls, and pressure injuries. --For pressure injuries they discussed rates in general. *The QAPI committee started a performance improvement project (PIP) for specific focus areas they were working on. *The current PIPs were for call lights and medication destruction. -Call lights was a concern that was brought up by the residents in their council meeting. -Medication destruction was an area the director of nursing (DON) thought still needed some work. *There had been quite a few changes in the leadership roles in the facility. *The administrator had started in his role in (MONTH) (YEAR). *The DON had started her role in (MONTH) (YEAR). *The MDS nurse was also new to her role within the last year. *RN [NAME] would be learning more about QAPI and being more involved in the future. Continued interview and record review of the attendance sheets for the QAPI meetings from (MONTH) (YEAR) through 3/28/18 revealed: *The administrator stated he was unable to find several of the attendance sheets. -When the new administration took over things changed. -For some reason they stopped keeping track of the attendees. *Their last list of attendees prior to the (MONTH) (YEAR) meeting was on 8/22/17. *The administrator stated they had a meeting in (MONTH) (YEAR), but there was no record of it. *They had no meeting in (MONTH) (YEAR). *During the 1/30/18 meeting they started keeping track of attendees again. -That was when they had noticed it was not getting done. *They had no QAPI meeting in (MONTH) (YEAR) or in (MONTH) (YEAR) yet. Review of the copies of attendees for QAPI from (MONTH) (YEAR) through 3/27/18 revealed:*There was no attendees listed for the 4/28/17 meeting. *The medical director had not attended the 5/23/17 meetings. *There were meetings held on 6/20/17, 7/18/17, 8/22/17. *There were copies of email invites for the meetings on 9/19/17 and 10/31/17, but there was no list of who actually attended. *They had no meeting in (MONTH) (YEAR). *The (MONTH) (YEAR) meeting had not been attended by the physician. -There was no proof the medical director had attended a meeting since (MONTH) (YEAR). Continued interview with the administrator, MDS coordinator, and RN [NAME] regarding QAPI revealed:*The leadership changes might have contributed to the concerns with the QAPI program. *They stated the medical director liked to attend and participated in the meetings. *There were only the two current PIPs, because they did not want to get overwhelmed with too many at one time. -They were planning to add more PIPs at the next meeting. *When they had their quarterly meetings with the medical director those were more in-depth discussions than during the monthly meetings in-between. -If a PIP needed to be added at a monthly meeting they would do that. *PIP were separate committees that reported to the QAPI committee. -They were trying to get direct care staff involved in the PIP committees. *They confirmed when they used QM data to find areas that needed to be worked on that would have been past concerns, since it was generated from resident MDS assessments. *They agreed QAPI should have been a proactive approach to problems and not reactive to old data. *They currently did not have a specific QAPI template they followed but were hoping to get that changed in the future. *When asked if any of the audits or follow-up from the previous surveys in (YEAR) had still been a part of the QAPI meetings they stated: -They thought they were done with those items. --Most had run their course. -They were aware the last survey in (MONTH) (YEAR) identified system concerns with pressure injuries. --The current survey found concerns again with pressure injuries. *The administrator stated the current leadership was asked to review the past deficiencies that would have been related to their department. *The MDS coordinator stated the president of the Custer market had indicated they should be looking back at the previous surveys and making that a part of the QAPI plan. -She thought that was back in (MONTH) (YEAR). *They felt corporate staff and consultants were available to them if they reached out for help. *The administrator stated QAPI should have been a focus during the day-to-day operation for everyone working there. *They confirmed they had not actively been working on PIPs for some of the concerns surveyors had identified including: -Pressure injuries. -Falls and interventions. -Investigations into residents' incidents and accidents. *The MDS coordinator stated falls had been a PIP in (MONTH) (YEAR), and they were doing better then. -It was not currently a PIP. -QAPI reviewed falls in general but not necessarily the interventions. *The administrator oversaw this facility and another long-term care facility. -He divided his time between the two and felt it worked well. -He was available to both facilities anytime they asked either in-person or by phone. -He felt the staff kept him informed and aware of what was happening. *They confirmed their QAPI program had not been effective in the past, and they would be working towards improvement. Review of the provider's undated QAPI Plan for (facility name) revealed:* .All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services.*Our QAPI plan includes policies and procedures to: -Identify and use data to monitor our performance. -Establish goals and thresholds for our performance. -Utilize resident, staff and family input. -Identify and prioritize problems and opportunities for improvement. -Systematically analyze underlying causes of systemic problems and adverse events. -Develop corrective action or performance improvement activities. *The QAPI committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. *The administrator has responsibility and is accountable to the board of directors and our corporation for ensuring that QAPI is implemented throughout our facility . *All department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representatives (if appropriate) and three additional staff will provide QAPI leadership by being on the QAPI committee . *The QAPI committee will meet monthly . * .The QAPI committee prioritize opportunities for improvement and determine which performance improvement projects will be initiated . *Our organization will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention . *Our QAPI committee will prioritize topics for PIPs based on the current needs of the resident and our facility. Priority will be given to areas that are problem-prone .", "filedate": "2020-09-01"}
{"rowid": 52, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-09-13", "deficiency_tag": 610, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YYKW11", "inspection_text": "Based on observation, record review, interview, and policy review, the provider failed to ensure two of two sampled residents (13 and 47) with incidents resulting in major injury were fully investigated and reported to the South Dakota Department of Health (SD DOH). Findings include: 1. Observation and interview on 9/11/18 at 10:30 a.m. of resident 13 revealed: *She used a wheelchair for locomotion. *She wore a Cam boot on her left foot. *She reported she had broken her foot when she had fallen from a bath chair a while ago. Review of resident 13's 6/13/18 nursing progress notes revealed: Bath aide requesting help to transfer resident off bath chair into w/c (wheelchair) assist x2 (of two) to stand while assist x1 (of one) to wipe bottom et pull up brief et pants; resident not cooperating; not letting go of sides of the bath chair; resident pulling on staff that was to be wiping et pulling up pants; too much time on lower extremities et resident started going down; resident was lowered slowly to the floor onto her knees; resident c/o (complained of) pain/discomfort to feet. Observation of resident 13 on 9/12/18 at 8:30 a.m. and of one unidentified traveling certified nursing assistant (CNA) and CNA B revealed: *They used a Hoyer lift to transfer her. *CNA B acknowledged the resident had slid from the shower chair about a month earlier. -That had resulted in her fracturing her left foot. *At the time of the fall the aides were attempting to position her in the new bath chair. -They could not get her far enough back in the chair, because it did not fit her correctly. -Also due to the design of the bath chair only one aide could reach the resident, because there was a bar that came down. --That prevented the staff from pulling the resident far enough back. -CNA B had not been working the day she fell . -It had been reported to them afterwards though they should not use the bath with that resident anymore. --They needed to give her a shower. Further observation and interview with CNA B on 9/12/18 at 11:29 a.m. of the bath chair used in the above incident revealed: *They could not get her pulled back all the way in the bath chair, and she did not fit in it properly. *She kind of stiffened up and you could not get her pulled far enough back in the chair. *She had started to slide and they could not pull her back, so they had hooked underneath her arms. -She was sat on the floor, so they could get the chair out of the way. *The next time she was going to have a bath they could not get her in the bath chair. -They had put her in the shower, because she did not fit in the chair. *She confirmed the chair was new. Review of the incident report for the above fall revealed the 6/13/18 progress note was documented and had the following additional information: *The resident was alert. *There were no injuries. *There were no witnesses. Interview on 9/12/18 at 4:23 p.m. with the director of nurses (DON) regarding resident 13 revealed: *The resident had fractured her left foot. *CNA B had accurately described what had happened when the resident slid from the chair. *There had not been a thorough investigation completed after the fall. *The fall with an injury had not been reported to the SD DOH, and it should have been. Review of the provider's 6/27/16 Abuse Investigations policy revealed: *Investigative Process: -3. The individual conducting the investigation will at a minimum: --a. Review the completed documentation forms. --b. Review the resident's medical record to determine events leaving up to the incident. --c . Interview the person(s) reporting the incident; --d. Interview any witnesses to the incident; --e. Interview the resident (as medically appropriate); --g. Interview all staff members who have had contact with the resident during the period of the alleged incident; -11. The results of the investigation will be recorded on approved documentation forms. -14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. 2. Observation on 9/11/18 at 3:02 p.m. of resident 47 revealed she had a raised, bruised area with a scab in the center on her forehead above her right eye. Review of resident 47's medical record revealed: *She had an unwitnessed fall in her room on 8/17/18. *Major injuries were noted. A big, bloody bump is noted on the forehead with 2 lacerations. *No documentation that incident had been reported to the SD DOH. Interview on 9/13/18 at 10:42 a.m. with the DON regarding the above incident revealed: *She confirmed it had not been reported to the SD DOH. *They had created a reference binder titled What To Do If that contained instructions for staff for various situations including reporting incidents with injury to the SD DOH. *Her expectation would have been for the above incident to have been reported to SD DOH within the required timelines. Review of the provider's undated Protocol for Department of Health State Reports located in the What To Do If binder revealed: *If you have a fall with major injury, resident to resident altercation, death other than natural cause, or suspected abuse/neglect you need to report this to the Department of Health. *If it is suspected abuse/neglect it MUST be reported within 2 hours. *All other incidents need to be completed before the end of your shift. Review of the provider's undated Event Reporting form located in the What To Do If binder revealed an event with major injury: *Was Reportable with-in 2 hrs (hours) for alleged Abuse/Neglect/serious injury. *Those events included: -Fall with major injury. -Resident to resident altercations. -Suspected abuse/neglect. -Elopements off of facility property. -Theft/misappropriation of funds. -Death other than natural causes. Review of the provider's revised 6/17/18 Fall Prevention/Management/Documentation policy revealed: *Any fall with injury is to be reported to the Department of Health. *If the fall was un-witnessed or the resident cannot tell you what happened notify the Department of Health. *If the resident is sent to the ER (emergency room ) for evaluation, notify the Department of Health. *If the fall was un-witnessed the interventions-action is noted and faxed to the state according to regulatory guidelines.", "filedate": "2020-09-01"}
{"rowid": 53, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-09-13", "deficiency_tag": 661, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YYKW11", "inspection_text": "Based on record review and interview, the provider failed to ensure one of one sampled resident (54) who was discharged home had a completed discharge summary. Findings include: 1. Review of resident 54's Discharge Summary revealed: *She had been discharged to home on 6/24/18. *A brief nursing summary had been written. *The document asked for a brief therapy, social services, activity, and dietary narrative summary. *All those areas had been left blank. Interview on 9/13/18 at 10:19 a.m. with the director of nurses regarding the above for resident 54 revealed: *When a resident was discharged she sent a request to the appropriate disciplines to complete the Discharge Summary. *It was her expectation for them to complete that document. -That had not been done for the resident. *A request for the policy on discharge summaries was made at that time. -None was received by the end of the survey.", "filedate": "2020-09-01"}
{"rowid": 54, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-09-13", "deficiency_tag": 692, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YYKW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (50) who was on Hospice services had an appropriate and timely assessment to ensure nutritional parameters were maintained. Findings include: 1. Observation on 9/11/18 at 11:30 a.m. of resident 50 revealed: *He ate at an assisted table during the noon meal. *His daughter was feeding him. Review of resident 50's 9/11/18 physician's orders [REDACTED].>*He was receiving Hospice services since his admission on 6/26/18. *His [DIAGNOSES REDACTED]. *He was on a regular diet with pureed texture. Review of resident 50's weights revealed: *On 6/26/18 he weighed 183.5 pounds (lb). *On 7/6/18 he weighed 177.9 lb. *No further weights had been obtained. Review of resident 50's 7/10/18 dietary progress note revealed: *Weight 7/6/18 176.5 lb. Weight on admission 183.5 lbs. Decrease of 7 lbs. 3.8% decrease. Diet is regular. Resident dines with supervision at meals. Intake at meals 2 breakfast refusals, averaging 75% at meals. BMI (Body Mass Index) = 27.6. %IBW (Ideal Body Weight) 119. *Resident has open areas on left side from tumors. Resident is on Hospice. Written by registered dietitian (RD). *There were no further dietary assessments. Review of resident 50's 7/20/28 care plan revealed: *Focus: I have nutritional problem r/t (related to) [DIAGNOSES REDACTED]. *Goal I will maintain adequate nutritional intake to support weight maintenance by participating in 3 meals a day. *Interventions addressed: a calm environment, inviting to activities that promoted additional intake, and serving the diet that was ordered by the physician. Interview on 9/12/18 at 3:18 p.m. with the consulting registered dietitian and the dietary services manager regarding resident 50 revealed: *He was on Hospice that meant he received palliative care. *They confirmed there had not been a weight on him for over two months. -They could not say for sure why that had been. --Sometimes weights were just not done by nursing, so they have no record. --She agreed they could ask for the staff to get his weight, but they had not done that. *There had been no laboratory tests done either to monitor his nutritional status. *Usually the RD monitored residents on admission, quarterly, or more often if there was a problem. *She agreed that because he was on Hospice would not mean he would not have been monitored. *A review of her facility weight record that listed all the residents noted: -His only two weights had been yellowed out. --There were no further weights after July. -She yellowed out weights when there was a variance in weights, such as noting his 7 lb weight loss from admission until July. *The RD confirmed it would have been difficult to monitor if his weight was being maintained if they were not weighing him. Interview on 9/12/18 at 11:09 a.m. with the director of nurses (DON) regarding resident 50 revealed: *They should have weighed all residents at least weekly. -It would not matter if he was on Hospice. *At that time a request was made to the DON to have the resident weighed. Interview on 9/12/18 at 2:00 p.m. with the DON regarding resident 50 revealed he had been weighed, and his current weight was 164 lb. That was a 19.5 lb weight loss since his admission on 6/26/18. Interview on 9/13/18 at 8:30 a.m. with resident 50's physician revealed: *The resident had been new to him since he was admitted in June. *He was admitted on Hospice with a [MEDICAL CONDITION] diagnosis. *With that being said they should still have been monitoring all the things that kept him comfortable. -That would include his skin condition, appetite and food intake, etc. *They might not send him to the hospital or do laboratory tests, but they would keep him comfortable. Review of the provider's undated Facility Nutrition Program revealed: A facility Dietitian will help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provides appropriate meals and other nutritional interventions. Review of the provider's (MONTH) 2009 Resident Nutrition Services policy revealed: *1. The multidisciplinary staff, including nursing staff, the Attending Physician and the Dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. *8. Significant variations from usual eating or intake patterns must be recorded in the resident's medical record. The Nurse Supervisor and/or Unit Manager shall evaluate the significant of such information and report it, as indicated, to the Attending Physician and Dietitian. Review of the provider's Dietary Consultant Agreement policy revealed The dietitian agrees to visit and counsel residents and chart, as needed to complete/monitor nutritional assessments, develop nutritional care plans, or instruct the residents on therapeutic diets.", "filedate": "2020-09-01"}
{"rowid": 55, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-09-13", "deficiency_tag": 740, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "YYKW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure two of three sampled residents (12 and 41) who exhibited symptoms of mental health instability had been assessed and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Random observations on 9/11/18 from 7:15 a.m. through 10:29 a.m. of resident 12 revealed he had: *Been sitting in a wheelchair (w/c) either in the hallway or inside of his room. *Been able to propel himself up and down the hallway. *Made non-sensical statements or would repeat what the surveyor stated when he was approached and attempted to visit with. Interview on 9/11/18 at 10:29 a.m. with certified nursing assistant (CNA) A regarding resident 12 revealed he had: *Been confused and alert to self only and was not interviewable. *A history of inappropriate behaviors towards staff and other residents. -Those behaviors had recently increased due to a change in his medications and acquiring a urinary tract infection [MEDICAL CONDITION]. Review of resident 12's medical record from 3/1/18 through 9/12/18 revealed: *An admission date of [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Required staff assistance to ensure all of his activities of daily living were met. -Required the use of anti-psychotic, anti-depressant, and hormonal medications to help with stabilizing his mood and behaviors. -Experienced an exacerbation in his behaviors when the physician attempted to decrease his anti-psychotic medication in (MONTH) (YEAR). --Those increased behaviors included: inappropriate advances and touching of female residents and staff; exit seeking behaviors with successful elopements out of the facility while attempting to locate his wife; hitting, kicking, and a decreased safety awareness which had resulted in several falls. -Required one-on-one monitoring by the staff during those periods of increased agitation and inappropriate behaviors. -Acquired a UTI and had required the use of an antibiotic to treat the infection. *On 5/21/18 the physician had written an order for [REDACTED]. *No documentation to support: -When the resident had been evaluated by the psychologist. -What recommendations the psychologist had for the resident to help him with those behaviors. Review of resident 12's psychotherapy progress note revealed: *On 7/2/18 the psychologist had completed an evaluation on the resident. -That evaluation had not been completed until forty-eight days after the physician had written an order for [REDACTED]. *The psychologist had made several recommendations for the staff to follow when assisting the resident during an increase in his behaviors. *The psychologist had not completed his review and signed the progress note until 9/13/18. *It had not been a part of the resident's medical record for the staff and physician to review to ensure appropriate care and services had been delivered to the resident. Interview on 9/12/18 at 10:27 a.m. with the social services designee (SSD) regarding resident 12 revealed: *She had confirmed the resident's medical record and documentation to support an increase in his behaviors from (MONTH) (YEAR) through (MONTH) (YEAR). *She confirmed there was no documentation to support: -When the psychologist had completed his consult on the resident. -What recommendations the psychologist had made for the staff to follow when assisting the resident during an increase in his behaviors. -The recommendations made by the psychologist had been available for the primary physician to review and approve. *She stated: -He comes in to the facility every week to see his residents. -I notify him when we get orders for him to see a resident. -I give him a completed clinical history form on any new residents for him to review. -He did not always follow-up with me or the staff on his recommendations. Sometimes he would. -He does not give us a list of who he is going to visit with when he is here. -We do not know when he will be in the facility. -He does not have a secretary to help him and does his own dictated notes. -It can be up to three months or more before we get his notes and recommendations in the facility. -Yes, this is a concern of ours and we have visited with him about it. *There was no system or procedure in place to ensure the psychologist: -Completed an evaluation on a resident with increased behaviors in a more timely manner to promote mental health well-being. -Completed and provided his progress notes and recommendations for the physician and staff to review in a more timely manner. 2. Observation on 9/11/18 at 12:03 p.m. of resident 41 revealed she had: *Been sitting in the dining room eating her noon meal. *Required staff support and cueing to complete that meal. *Made no attempt to respond verbally when spoken to. Review of resident 41's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She had: -Required staff assistance to ensure all of her activities of daily living were met. -Been able to move around the facility independently with the use of a w/c. -Required the use of anti-psychotic and anti-depressant medications to help with her mood and behaviors. *On 5/3/18 she had been: -hospitalized due to an exacerbation of her behaviors. --Those behaviors been exit seeking, hitting, kicking, screaming, and yelling at other residents and staff. -Considered a safety risk for herself and others. *On 5/7/18 she had: -Been readmitted to the facility after the hospital had determined she was no longer a safety risk to herself and others. -Continued to exhibit the behaviors above and required one-on-one monitoring. -Denied admittance to other facilities to assist her with the stabilization of her mental health well-being. *The physician had written an order for [REDACTED]. *No documentation to support the psychologist had been: -Notified of those orders until 7/24/18. -In the facility to complete an evaluation of the resident. 3. Interview on 9/13/18 at 9:45 a.m. with the director of nursing and administrator regarding residents 12 and 41 revealed: *They: -Confirmed the above medical record reviews for those residents. -Had no explanation for the missing order for resident 41. -Had no process in place to ensure the psychologist had received his orders. *The DON stated: -When we get consult orders I will give them to the (staff name) (SSD) during stand-up meetings Monday through Friday. -I'm not sure what her process is with the order after that. *They: -Confirmed the psychologist was a consultant for the facility and residents. -Agreed: --The expectations for the timeliness of his consults/evaluations, availability of his recommendations/documentation should have been the same as all of the other providers. --His reports and recommendations should have been in place to ensure the mental health well-being of the residents had occurred in a more timely manner. -Had no policy or procedure in place to ensure those expectations would have occurred.", "filedate": "2020-09-01"}
{"rowid": 56, "facility_name": "MONUMENT HEALTH CUSTER CARE CENTER", "facility_id": 435032, "address": "1065 MONTGOMERY ST", "city": "CUSTER", "state": "SD", "zip": 57730, "inspection_date": "2018-09-13", "deficiency_tag": 849, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YYKW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and hospice agreement review, the provider failed to ensure one of one sampled resident (50) who received Hospice services had Hospice integrated into the resident's care plan. Findings include: 1. Review of resident 50's 7/9/18 Minimum Data Set (MDS) assessment revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He received hospice services. Review of resident 50's 7/16/18 care plan revealed: *Focus: He had end stage adult T cell [MEDICAL CONDITION]. He was weak and confused and was on Hospice. -Interventions addressed all activities of daily living (ADL) that were to have been provided by facility staff. *Focus: I have end [MEDICAL CONDITION]. I have tumors/[MEDICAL CONDITION] on my left rib cage. I am at risk for pain r/t (related to) this issue and end of life. I am on Hospice services. -Interventions addressed all medications to have been administered by the facility nurses. --There were no interventions addressing how Hospice was utilized in pain management. *Focus: I have a psychosocial well-being problem r/t distractibility/inability to concentrate. End stage disease. -There were no interventions addressing how they would utilize Hospice in addressing psychosocial needs. Interview on 9/13/18 at 10:00 a.m. with the MDS coordinator revealed the care plan did not address what Hospice services was providing. Review of the provider's undated Comprehensive Care Plan policy revealed: *An interdisciplinary comprehensive care plan that includes measurable objectives, goals and timetables to meet the resident's needs is developed by the Interdisciplinary Team (IDT) for each resident and reflects the resident's current status. Accurate and timely care planning is the roadmap for provision of quality care. *It did not address Hospice specifically. Review of the undated Hospice Service Agreement revealed: *Cooperation with Hospice Staff. Center shall cooperate with Hospice staff members in carrying out each Patient's P[NAME] (plan of care), including participation in Hospice's symptom control protocols. *Center shall make Center staff members available for participation in interdisciplinary group conferences as needed to coordinate the care of Patients and participate in quality assurance activities conducted by Hospice.", "filedate": "2020-09-01"}
{"rowid": 57, "facility_name": "WESTHILLS VILLAGE HEALTH CARE FACILITY", "facility_id": 435033, "address": "255 TEXAS ST", "city": "RAPID CITY", "state": "SD", "zip": 57701, "inspection_date": "2017-06-14", "deficiency_tag": 241, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "WA4911", "inspection_text": "Based on observation, interview, policy review, and quality assurance performance improvement (QAPI) review, the provider failed to: *Create a positive and respectful dining experience for 6 of 14 residents (3, 5, 7, 8, 9 and 16) during two of two observed meals in one of two dining rooms (assisted). *Ensure staff provided assistance with eating in a dignified manner for two of two randomly observed residents (9 and 15). *Ensure one of one randomly sampled resident (17) had not received medication in a public area. *Ensure staff answered call lights in a respectable and and followed up in a timely manner. Findings include: 1a. Observation on 6/13/17 from 10:30 am. through 11:25 a.m. of the assisted dining room (ADR) during brunch revealed: *Residents 15 and 16 had already received their meals and were being assisted by certified nursing assistant (CNA) B. *Resident 9 had been served her meal at 10:30 a.m. and resident 8's meal had been served at 10:45 a.m. *At 11:05 a.m. CNA B left the table with residents 15 and 16 and cued resident 9 to eat her meal. *She then put a bite of food on the fork and cued resident 8 to eat. *She did not sit down with the residents during that time. *She went back and while standing helped resident 15 to take another bite of her food. *She was the only staff member in the assisted dining room until 11:00 a.m. *Three other unidentified CNAs then came into the dining room and assisted residents 3, 5, 7, 8, and 9 with their meal. *Resident 8 and 9's meal had not been reheated. *Resident 14 had received her meal at 10:55 a.m. and her table mate, resident 7, had not received her food until 11:10 a.m. Surveyor: b. Observation on 6/13/17 from 4:40 p.m. to 5:30 p.m. of the main dining room (MDR) and in the ADR revealed: *Five staff consisting of food service and CNAs were available to serve eighteen residents in the MDR. *CNA B was the only available staff to serve and assist fourteen residents in the ADR. She tried to serve, assist, cue, and redirect all fourteen residents during the meal. *Residents 15 and 18 had been brought to the ADR and sat for approximately fifteen minutes before they were served. *Resident 5 sat at a table where resident 13 had been served her food at approximately 4:40 p.m. Resident 5 sat for another twenty-five minutes before he was served. *CNA B tried to assist any and all residents in the ADR. But some residents sat with their food in front of them and were unable to eat without assistance. Surveyor: c. Interview on 6/13/17 at 5:15 p.m. with the certified dietary manager and dietary aide A revealed: *Typically when a resident came into the dining room they were served. *They tried to serve all residents at one table at the same time. *It was more difficult in the main dining room to have served all the residents at one table together. Residents could come into the dining room anytime during the hour the meal had been scheduled. Continental breakfast was served from 7:00 a.m. through 9:00 a.m., brunch was served from 10:30 a.m. through 11:30 a.m., and the evening meal was served from 4:30 p.m. through 5:30 p.m. *Residents in the assisted dining room were served when a CNA was available to assist them. Even if other residents at the table had to wait to have been served their meals. *They had tried to work with nursing staff to not have the CNAs bring the residents into the assisted dining room until they were available to help them. *They had worked with the director of nursing on that Works for a bit and then slides back. Surveyor: Interview on 6/14/17 at 9:00 a.m. with the director of health care and the compliance director regarding the staffs' work flow in the assisted dining room revealed: *They and the director of nursing (DON) had addressed the work flow issue of residents getting their food before staff were available to assist them with eating in the QAPI minutes for (MONTH) (YEAR) and (MONTH) (YEAR). -Residents were being brought to the assisted dining room and served their food before staff were available to assist them. *In (MONTH) (YEAR) they and the DON had performed an audit to ensure residents who needed assistance with eating had not received food items until staff were present to assist them with eating. *The facility had not addressed the work flow issue in the (MONTH) (YEAR) QAPI minutes. Staff had felt the work flow in the feeding assistance dining room had improved. *There was no QAPI meeting in (MONTH) (YEAR). *The (MONTH) (YEAR) QAPI minutes revealed there was still a work flow issue with residents brought to the assisted dining room and served their food before staff were available to assist them with eating. *They agreed the work flow issue needed improvement. *They did not have a policy, procedure, or audits for the work flow in the assisted dining room. Review of the provider's 1/7/15 Meal Service policy revealed: *Residents who could no longer feed themselves would have been provided assistance. *Residents that required assistance with dining would have been assisted to that dining room. *Staff were assigned to the assist dining room at mealtimes. Review of the provider's undated Meal Service and Distribution policy revealed: *A comfortable, attractive atmosphere would be maintained in the dining room area. *Food would have been delivered promptly to ensure quality of food for the residents. *Nursing service was responsible for assisting at meal time following what was appropriate for residents' needs. *Residents' meals were to have been distributed promptly in the dining room by the dietary staff and nursing services. *Nursing staff would have been in the dining room during meal service to assist residents with eating and to handle any emergency that might have arisen. 2. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with a group of seven residents revealed they had not liked it when plastic silverware was used during the continental breakfast. The surface of the silverware was smaller and food easily slid off making it harder to eat. 3. Observation and interview on 6/13/17 at 1:15 p.m. during the resident council meeting revealed: *Resident 17 was provided medication from unlicensed assistive personnel (UAP) C. *He stated he did not like his medication to be given during the meeting. *He felt UAP C could have waited or asked him if it was alright to interrupt him. 4a. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with seven residents during a resident council meeting revealed:*Call lights were usually answered in a timely manner. *The problem was the staff would state to them I'll be right back, OK, or Just a sec. *The staff then did not return to assist them. *Four of the residents in the group felt they needed to learn patience due to waiting. b. Interview on 6/14/17 at 10:00 a.m. with resident 12 revealed there were times when he would wait and wait for his call light to be answered. He stated they would come and turn off the light and state they would be right back. Or they would come and say I'll be right there! but not come back until much later. He understood they had other residents to attend to, but it seemed staff took a lot longer to answer his call light in the morning, evening, and during the night. c. Review of the provider's 1/7/15 Call Lights policy revealed: Purpose: To ensure call lights are answered in a reasonable amount of time. The facility goal is an average response time of 10 minutes. Procedure: 1. When the call light is activated, staff members will answer and assist. 2. When staff members are working with another resident and if possible, they will acknowledge the resident and call light, and give the resident an estimated return time. Should the resident need immediate attention, staff will communicate with the charge nurse for assistance. 3. If the call light rolls over to the charge nurse, they will provide follow-up appropriate to the situation. The Director of Nursing or designee will observe and monitor call light usage and response by staff members. Trending and patterns will be reviewed as needed at facility Quality Assurance meetings.", "filedate": "2020-09-01"}
{"rowid": 58, "facility_name": "WESTHILLS VILLAGE HEALTH CARE FACILITY", "facility_id": 435033, "address": "255 TEXAS ST", "city": "RAPID CITY", "state": "SD", "zip": 57701, "inspection_date": "2017-06-14", "deficiency_tag": 281, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "WA4911", "inspection_text": "Based on record review, observation, interview, and policy review, the provider failed to follow professional standards for administration of medications by one of one observed licensed practical nurse (LPN) (D) for one of one sampled resident (6) who received medication per an enteral tube. Findings include: 1. Observation on 6/13/17 at 9:20 a.m. of LPN D while she administered medications to resident 6 revealed she: *Prepared the medications for the resident referring to the medication administration record. *She crushed them and mixed them with water individually. *Took those medications and 150 cubic centimeter (cc) of water to the resident's room. *Instilled the medications through the resident's enteral tube. *Flushed the enteral tube with water between each medication administered. *Flushed the enteral tube with a 150 cc bolus of water after the last medication had been administered. Interview on 6/13/17 at 11:00 a.m. with LPN D regarding resident 6 confirmed she had not verified placement of the enteral tube. She had not used a stethoscope to listen before administering his medications. She stated she confirmed tube placement before administering nourishment but not for medications. Interview on 6/13/17 at 11:45 a.m. with the administrator and the director of nurses confirmed the enteral tube placement should have been verified. It should have been done before the resident's medications and water had been administer into that tube. Review of the provider's (MONTH) (YEAR) Enteral Tubes Administration of Formula, Medications, and Liquids policy and procedure revealed placement of the enteral tube was to have been verified With auscultation using 150 cc of air.", "filedate": "2020-09-01"}
{"rowid": 59, "facility_name": "WESTHILLS VILLAGE HEALTH CARE FACILITY", "facility_id": 435033, "address": "255 TEXAS ST", "city": "RAPID CITY", "state": "SD", "zip": 57701, "inspection_date": "2019-10-09", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G9N411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure: *One of one unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to ensure the prepackaged medication name received from the pharmacy matched the names on the Medication Administration Record [REDACTED]. *The blood glucose meter had been properly sanitized according to policy by one of one observed UAP (A). *There was a documentated rationale and specified duration for a PRN (as needed) [MEDICAL CONDITION] medication for one of four sampled residents (4) whose medical record was reviewed for unnecessary [MEDICAL CONDITION] medications and medication regimen review. Findings include: 1a. Observation on 10/9/19 at 8:04 a.m. of UAP A while she administered medications to resident 10 revealed the resident's packets of medications stated: *Sentry Senior take 1 tablet orally daily in the morning. *[MEDICATION NAME] 500 MG (milligrams) Take (2) tablets orally twice daily for pain. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. b. Observation on 10/9/19 at 8:45 a.m. of UAP A while she administered medications to resident 15 revealed the resident's packets of medications stated: *Fiber-Lax Take 1 tablet by mouth twice a day.*Thera M Take 1 tablet by mouth every morning. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. c. Interview on 10/9/19 at 8:55 a.m. with UAP A regarding the above for residents 10 and 15 revealed: *UAP A stated she: -Just knew Sentry Senior was the same as [MEDICATION NAME] Silver and [MEDICATION NAME] was the same as [MEDICATION NAME]. -Just knew Thera M was the same as a multivitamin and Fiber-Lax was the same as calcium polycarbophil 625 mg tablet twice a day. -Knew by process of elimination, because she poured all the residents other medications into the cups and these were the medicines remaining. -Just figured them out that way. -Had made the above decisions herself. -Had not asked a licensed nurse to confirm the above medications had been interchangeable. Interview on 10/09/19 at 9:50 a.m. with the consultant pharmacist confirmed the medication names on the packets of medications should match the MARs exactly. Interview on 10/9/19 at 10:00 a.m. with the director of nurses (DON) regarding the above confirmed the medication names on the packages should have matched the medication names on the MARs. Review of the providers 11/11/15 Medication Passing Procedure policy revealed: *Each nurse/med aide (UAP) will be responsible for all medications on their assigned wings. MAR indicated [REDACTED] *Each individual medication was to have been checked with the MAR for the right resident name, right medication, right dose, right time, right route, right effect, right form, and right documentation. Review of the provider's undated Med Aide job description and performance review revealed the medication aide would: Demonstrate proper administration of medication under the supervision of the licensed nurse. 2. Observation and interview on 10/9/19 at 10:21 a.m. with UAP A while she disinfected the blood glucose meter revealed she: *Wiped the blood glucose meter with a Sani-Cloth bleach wipe. *Stated it usually dried between one and one-half minutes to two minutes. *Often waited five minutes to be sure it was dry before she used it for the next resident. *Had been unaware of what the policy for cleaning of the blood glucose meter said to do. Interview on 10/09/19 at 10:40 a.m. with the DON regarding the glucometer disinfecting process confirmed UAP A had not followed their policy. She stated, We just covered about that. Review of the provider's (MONTH) (YEAR) Glucose Meters Cleaning and Disinfecting policy revealed: *The surface of the blood glucose meter was to have been wiped until completely wet. *Let stand for four (4) minutes, ensuring treated surface remains visibly wet. Use additional wipes if needed to assure continuous wet contact time. 3. Observation on 10/8/19 between 8:09 a.m. and 9:48 a.m. revealed resident 4 was in her room in bed asleep. Observation again at 10:06 a.m. revealed: *Nursing staff had changed the resident's [MEDICATION NAME]. -She was calm. *She was taken to the bathroom using a mechanical lift. -The resident voiced no concerns. Observation again at 1:24 p.m. revealed the resident was in a chair in her room watching television, and she voiced no concerns. Review of resident 4's 9/28/19 Minimum Data Set (MDS) assessment revealed: *Her [DIAGNOSES REDACTED]. *Her Brief Interview for Mental Status assessment score was fifteen indicating she was cognitively intact. Review of resident 4's (MONTH) 2019 through (MONTH) 2019 MARs revealed: *There was an order for [REDACTED]. -The start date of that order was 7/17/18. *The resident had used [MEDICATION NAME] three times on three separate days during (MONTH) for a jumpy leg, pain, and anxiety. *The resident had used [MEDICATION NAME] ten times on ten separate days during (MONTH) for anxiety, nervousness, concerns about dying, an appointment, and an inability to urinate. *The resident had used [MEDICATION NAME] six times on six separate days during (MONTH) for nervousness, anxiety, and sharp chest pains. *The resident had used [MEDICATION NAME] four times on four separate days during (MONTH) for anxiety, mild nausea, restlessness, and not feeling right. *The resident had used [MEDICATION NAME] one time during (MONTH) for not feeling good. *The use of PRN [MEDICATION NAME] had been documented as effective. Review of the 5/10/19 physician's visit progress note for resident 4 revealed: *Current resident medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief complaint: -Resident 4 is being seen for her regular recertification exam (examination), management of her chronic illnesses as listed in the past medical history, and for management of her medications. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 7/15/19 physician's visit progress note for resident 4 revealed: *Current medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief Complaint: -Resident 4 is seen for her regular recertification exam, monitoring of her chronic illnesses as listed in the past medical history and for management of her medications. There's been no interval change in her health status. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 9/19/19 physician's visit progress note for resident 4 revealed: *It was not yet completed or signed by the physician. *There was a signed and dated physician's orders [REDACTED]. -By signing below, I acknowledge the following: --Current orders have been reviewed and approved. --Current [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 through (MONTH) 2019 monthly Consultant Pharmacist's Progress Notes regarding resident 4's PRN [MEDICATION NAME] use revealed: *The consultant pharmacist recommendations created between 6/1/19 and 6/13/19 had included a record of the resident's use of PRN [MEDICATION NAME] use from (MONTH) (YEAR) through (MONTH) 2019. *The consultant pharmacist's recommendations between 7/1/19 and 7/12/19 revealed: -Consulted by nursing to evaluate pain and anxiety to develop a pain plan. Given the increase in both PRN [MEDICATION NAME] and [MEDICATION NAME] (pain medication) and that they are frequently given together or within 1 hour of each other they appear to be correlated. -The pharmacist advised the physician: the .last 2 times the [MEDICATION NAME] was increased there was a decrease in pain scores and PRN pain/anxiety medication usage. -There was no subsequent change made to the PRN [MEDICATION NAME] order by the physician. *The consultant pharmacist's recommendations between 8/1/19 and 8/13/19 and recommendation between 9/1/19 and 9/11/19 revealed there was no discussion regarding the resident's use of PRN [MEDICATION NAME]. Interview on 10/9/19 at 1:40 p.m. with the DON regarding resident 4's use of PRN [MEDICATION NAME] revealed: *She would have to review the resident's record to determine if there was physician documentation that had specified a duration of use for the PRN [MEDICATION NAME]. *She would have to review the resident's record to determine if there was physician documentation that had specified a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. Interview on 10/9/19 at 2:23 p.m. with the administrator regarding resident 4's use of PRN [MEDICATION NAME] revealed: *There was no physician's documentation that had specified a duration of use for the PRN [MEDICATION NAME] or a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. *She had referred the matter to the consultant pharmacist. Interview on 10/9/19 at 2:30 p.m. with the consultant pharmacist regarding resident 4's use of PRN [MEDICATION NAME] revealed: *He had no record he had contacted resident 4's physician about specifying a duration of use for the PRN [MEDICATION NAME]. *He had no record he had contacted resident 4's physician about documenting a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. A copy of the provider's policy regarding PRN [MEDICAL CONDITION] Medication Use was requested on 10/9/19 at 3:15 p.m. from the DON. However the facility did not use such a policy, and no comparable policy was provided.", "filedate": "2020-09-01"}
{"rowid": 60, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2018-05-16", "deficiency_tag": 610, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4XMM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, and record review, the provider failed to complete and fully investigate a staff-to-resident incident for one of one sampled resident (33) who had complaints of severe pain after a facility acquired injury had occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support: -An incident report was completed after the injury had been reported by CNA I on 5/12/18. -A formal investigation was completed to rule out abuse and ensure no major injury had occurred to the resident's left leg. -Systems, protocols, and education were provided and implemented to ensure this type of incident and injury would not have occurred again. *The physician had not been notified of: -The incident and injury that had occurred to the resident's left leg. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had give her for those complaints of discomfort. Refer to F697, finding 1.", "filedate": "2020-09-01"}
{"rowid": 61, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2018-05-16", "deficiency_tag": 686, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "4XMM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (44) who required staff assistance with care had not developed a facility acquired pressure injury. Findings include: 1. Observation on 5/15/18 at 8:30 a.m. of resident 44 revealed she: *Had been: -In the dining room eating her breakfast. -Sitting in a Broda wheelchair (w/c) with pressure relieving boots on both of her feet. -Wearing a specialty brace that started at her neck and extended down to her waist. -Able to move her arms without difficulty, but no spontaneous movement of her legs was noted. -Complaining of discomfort and requested an unidentified staff member to take her back to her room. *Appeared weak, frail, and her hair was unkempt. Observation and interview on 4/15/18 at 8:45 a.m. with resident 44 revealed: *She had been: -In her room and sitting in her Broda w/c. -Alert with some confusion to date and time. -Listening to country music on her television and watching the activities going on outside of her window. *She: -Had just received some pain medication and was feeling better. -Continued to wear the speciality brace and pressure relieving boots to both of her feet. -Was not able to remember why she had to wear a specialty brace or boots to both of her feet. *Her: -Feet had been resting on the footrest of the w/c. -Left foot and leg were slightly turned inward. Interview on 5/15/18 at 9:10 a.m. with licensed practical nurse (LPN) J regarding resident 44 revealed: *She had: -Been recently admitted with a compression fracture in her back. -Required the use of a specialty brace for safety and support while the fracture healed. -A wound located on her left heel. -Acquired that pressure injury while she had been receiving care and services in the facility. *LPN J stated She has a black area on her left heel. *The surveyor had: -Informed LPN J and certified nursing assistant (CNA) B she would like to watch them with personal care throughout the day. -Been informed by the staff the resident would turn on her call light if she needed assistance to go to the bathroom or wanted to lay down in her bed. Random observations on 5/15/18 from 8:30 a.m. through 4:30 p.m. of resident 44 revealed: *From 8:30 a.m. to 10:00 a.m. she had been in her room sitting in her Broda w/c as observed above. *From 10:10 a.m. through 11:15 a.m. she continued to sit in her Broda chair as observed above but had been taken outside for an activity. *At 11:50 a.m.: -She continued to sit in her Broda w/c but had been brought back to her room. -CNAs A and B approached the surveyor to watch personal care on her and another resident. --They provided personal care for the other resident first. *At 12:30 p.m. CNAs A and B had prepared to assist the resident with personal care and toileting. -The resident was not in her room and had been taken down to the dining room for dinner. *At 12:35 p.m. she had been observed in the dining room eating her dinner. *At 1:30 p.m. CNAs A and B assisted the resident with laying down in her bed and personal care. -They positioned her onto her back, left the pressure relieving boots on, and elevated her feet off of the bed with a pillow. --She remained in that position from 1:30 p.m. until 4:30 p.m. *At 4:30 p.m. CNAs K and L assisted the resident to get out of the bed and into her Broda w/c. *From 8:30 a.m. through 4:30 p.m. she had been assisted with repositioning twice. Interview on 5/15/18 at 12:33 p.m. with CNA A regarding their policy for repositioning residents who required staff assistance stated: *We have an every two hour repositioning schedule to follow. *We didn't get to her this morning before she went outside and down to the dining room. Observation on 5/15/18 at 1:45 p.m. of resident 44's left heel with CNA B revealed: *There was a blackened area on her left heel. *The pressure injury was: -Located on the inner aspect of the left heel. -Approximately 2 centimeters (cm) in length and 1.5 cm wide. -Uncovered and opened to the air. Review of resident 44's medical record on 5/16/18 at 12:50 p.m. with the Minimum Data Set (MDS) assessment coordinator revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to: -Assist her with all of her mobility needs (transferring from place-to-place and moving in bed) and activities of daily living (ADL). -Implement any preventative interventions to ensure skin breakdown would not have occurred. *Her 4/5/18 admission nursing physical assessment identified no skin concerns to her left heel. *She had: -A Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. -Been capable of making her needs known. -Been admitted with no opened wounds or pressure injuries to her left heel. *Her Braden Scale score on 4/15/18 had been a sixteen. --That score had indicated she was at mild risk for skin breakdown. *On 4/16/18: -A pressure relieving distribution mattress had been applied to her bed. -The staff were to have elevated and off-loaded her heels when in bed. *On 4/23/18: -The charge nurse had documented an area of concern to her left heel. -The left heel was pink and boggy. -The size, type, and stage of the pressure injury had not been documented. -There was no documentation to support the family and physician were notified. -That area of concern had been eighteen days after her admitted . *On 5/2/18: -The left heel wound measured 2 cm x(by) 3.5 cm, and the skin underneath of the pink area was light purple in color. -The staff had been directed to apply Hydrogaurd to the wound and relieve pressure using heel protectors and pillows. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. *On 5/4/18: -A weekly skin assessment had been completed by the charge nurse. -The wound had been dark purple in color. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. *On 5/10/18 and 5/11/18: -The charge nurse had documented the wound was black in color, dry, and had no change in size. -The physician assessed the wound on 5/10/18 and had ordered Hydrogaurd to be applied to the left heel ulcer twice a day. --That order had not identified what type of ulcer the wound was nor the stage. *On 5/10/18 was the first documentation to support the physician had been notified of the wound to her left heel. -That was eighteen days after the area of concern to her left heel had been identified. Review of resident 44's 4/25/18 initial care plan summary revealed: *The summary had been completed by the MDS assessment coordinator and was reviewed with the resident's daughter on that date. *The summary had identified an area of concern to her left heel and it required close monitoring. *The staff were to have off-loaded her heels with pillows or use foam heel protectors. -No documentation in the medical record to support those heel protectors were initiated before 5/2/18. *The resident was using a pressure redistributing mattress. Review of resident 44's 4/16/18 comprehensive care plan revealed: *A focus area: Skin integrity: -That focus area was not developed until 4/25/18 and was two days after an area of concern had been identified to her left heel. *The goal for that focus area was: Skin integrity-maintain. *Interventions for that focus area: -Were the same as documented above by the charge nurses. -Supported the dates for initiation as documented above by the charge nurses. *The dietary department had not updated the care plan to reflect nutritional interventions were put in place to support and promote healing of the wound. Interview on 5/16/18 at 12:50 p.m. with the MDS assessment coordinator at the time of the medical record review for resident 44 revealed she had confirmed: *Preventative measures were not implemented in a timely manner to ensure an adverse event for the resident had not occurred. *The staff were reactive versus proactive in ensuring preventative measures were in place, so that a pressure injury had not occurred during the resident's care in the facility. *The staff should have included the resident's health condition upon admission when utilizing the Braden Score assessment to determine the risk level of skin breakdown. *The resident had been at risk for skin breakdown and should have been repositioned every two hours. *We have been trying to keep her life as real as we can. *I never thought about off-loading while sitting in a Broda w/c. *Yes, the Braden Score is a good resource, but we should really be reviewing the resident as a whole. *Yes, the residents do have the right to not acquire a wound or have a wound worsen while under our care. *I can't say I agree that her wound worsened. I believe a wound has to evolve to see what it really is first and her wound was never open. *The charge nurse had been responsible to notify the physician, family, and dietician upon the identification of a wound. *The dietary department should have updated their care plan to support their involvement with the wound healing process. Interview on 5/16/18 at 3:40 p.m. with the director of nursing and administrator regarding resident 44 confirmed and supported the interview above with the MDS assessment coordinator. Review of the provider's (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed: *Purpose: To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers to: -Systematically assess and document skin risk factors. -Implement skin-protection components of care. -Provide appropriate treatment when indicated. *Policy: -Interventions were to be implemented based on the Braden Scale Score assessment. -At Risk: Braden Scale Score: 15 to 18 - weekly head-to-toe skin inspection by licensed nurse. -Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition, and hydration, and minimizing pressure. -When a pressure ulcer or wound is discovered, whether upon admission or thereafter, the licensed nurse on duty is responsible for notifying the physician, the resident's family, the Clinical Care Coordinator, Assistant Director of Nursing, and dietician. *Assessment and Documentation: -Documentation should include: location, stage, size, undermining/tunneling, wound bed tissue type. *Treatment: A physician order [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 62, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2018-05-16", "deficiency_tag": 697, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4XMM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, and record review, the provider failed to ensure adequate pain control was monitored, reviewed, and appropriate interventions were implemented for one of one sampled resident (33) who had complaints of increased pain after a facility acquired injury occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support: -An incident report was completed after the injury had been reported by CNA I on 5/12/18. -A formal investigation was completed to rule out abuse and ensure no major injury had occurred to the resident's left leg. -Systems, protocols, and education were provided and implemented to ensure this type of incident and injury would not have occurred again. *The physician had not been notified of: -The incident and injury that had occurred to the resident's left leg. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had given her for those complaints of discomfort. Review of resident 33's 5/14/18 hospice nurse's notes revealed: *The resident had been complaining of her legs hurting earlier that day. *The staff had reported to the hospice nurse that the resident's leg was twisted during a transfer yesterday (5/13/18). *The resident had not required extra pain medication for discomfort. *The resident's pain control had been assessed with [REDACTED]. *A trace amount of [MEDICAL CONDITION] was observed to both of her lower legs, ankles, and feet. *No documentation to support a bruise was observed on her lower left leg. Review of resident 33's 5/14/18 hospice social services note revealed: *The resident had said she was having a lot of pain in her hip, and she had stated she Thinks it is broke. *An unidentified nurse had reported to her that the resident's Knee got bumped on the door frame over the weekend. *She had pain medication for it, and it should have taken effect shortly. *Staff feel it is not broke, more of a muscle pull. Review of resident 33's 5/15/18 registered nurse (RN) F's nursing documentation revealed: *She had completed a late entry for her interview and assessment of the resident that had occurred on 5/12/18 at 4:45 p.m. *On 5/12/18: -CNA I reported she had bumped the resident's left foot on the wall while taking her to the dining room in her Broda chair. -Resident 33 had complained of pain in her right foot, and then she had said it was her left foot. -There was swelling, but that had been usual for her. -Will monitor and report to (physician's name), any changes or signs of fracture. *Her late entry for the resident's incident with CNA I had occurred three days later and had occurred during the facilities recertification survey. *No documentation to support: -Where the swelling had been observed. -An incident report had been completed. Review of resident 33's 5/15/18 RN D's nursing documentation revealed: *She had completed a late entry for her assessment of the resident that had occurred on 5/12/18. *On 5/12/18 at 4:45 p.m.: -Resident was in so much pain when she was sit (sat) up from bed and place in the recliner. -The resident had complained her foot hurt, and RN D had checked her left leg from the knee down to her foot. *She had noted: -A fading bruise on the lower part of her shin. -Very tender to touch, the resident was yelling and grimacing when her legs had been elevated. -[MEDICATION NAME] had been given for discomfort. -She was still agitated and grimacing an hour after the pain medication had been given. -The resident stated I don't get relief and Put me up. *The nurse noted that was excruciating pain. *Her late entry of that assessment was three days later after the incident and had occurred during the facilities recertification survey. *No documentation to support: -An incident report had been completed. -The physician had been notified: --Of her assessment of the resident's leg and increased pain. --The pain medication was ineffective. Review of resident 33's 5/16/18 RN E's nursing documentation revealed: *She had completed a late entry for her assessment of the resident that had occurred on 5/14/18. *On 5/14/18 at 1:08 p.m.: -The resident had pain when the staff were assisting her with getting up. -The resident had stated It hurts, its hurts. -She had been medicated with Tylenol, [MEDICATION NAME], and [MEDICATION NAME]. --The [MEDICATION NAME] had been given again after an hour. -A warm pack had been applied to her left lower leg. *Her late entry of that assessment was two days later and occurred during the facilities recertification survey. *No documentation to support: -The nurse had assessed what the resident's left leg looked like. -The physician was notified of her increased pain with no relief after several pain medications had been given. Review of the provider's undated RN/Charge Nurse job description revealed: *Responsiveness: -Follow through and follow up. -Anticipate and respond to individual's needs. *Task 1 - Performs Nursing Task: -Contacts physician, establishes working relationship and initiates ongoing information exchange. -Provides professional nursing care to residents. -Administer professional services. -Monitor seriously ill residents as necessary. -Notify physician and next-of-kin when there are any changes in resident's condition. *Task 2 - Care Planning and Record Keeping: -Consistently & thoroughly completes documentation in a timely manner, including initiating medication & treatment administration records. -Completes/supervises medical record. *Task 3 - Supervisory Duties/Roles Knowledgeable status and needs of residents and communicates effectively with team members. Review of Potter/Perry's 2013 ninth edition; Fundamentals of Nursing; Chapter 44 page 1,022 on Pain Management revealed: *Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain. Critical thinking attitudes and intellectual standards ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief while balancing treatment benefits with treatment-associated risks. Successful pain management does not necessarily mean pain elimination but rather attainment of mutually agreed-on-pain-relief goal that allows patients to control their pain instead of the pain controlling them. *Nurses approach pain management systemically to understand and treat a patients pain. *The American Nurses Association (ANA, 2005) upholds that pain assessment and is within the scope of every nurse's practice. Review of Potter/Perry's 2013 ninth edition; Fundamentals of Nursing; Chapter 44 page 1,023 on Pain Management revealed: *Routine Clinical Approach to Pain Assessment and Management: ABCDE: -A: Ask about pain regularly. Assess pain systematically. -B: Believe patient and family in their report of pain and what relieves it. -C: Choose pain control options appropriate for the patient, family, and setting. -D: Deliver interventions in a timely, logical, and coordinated fashion. -E: Empower patients and their families. Enable them to control their course to the greatest extent possible.", "filedate": "2020-09-01"}
{"rowid": 63, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2018-05-16", "deficiency_tag": 710, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4XMM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support the physician had been notified of: -The incident and injury that had occurred to the resident's left leg on 5/12/18. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had give her for those complaints of discomfort. Refer to F697, Finding 1. Based on observation, interview, and record review, the provider failed to ensure physician notification and involvement had occurred in a timely manner for: *One of one sampled resident (44) with a facility acquired pressure injury. *One of one sampled resident (33) with increased pain after a facility acquired injury. Findings include: 1. Review of resident 44's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to: -Assist her with all of her mobility needs (transferring from place to place and moving in bed) and activities of daily living (ADL). -Implement any preventative interventions to ensure skin breakdown would not have occurred. *Her 4/5/18 admission nursing physical assessment identified no skin concerns to her left heel. *She had been admitted with no open wounds or pressure injuries to her left heel. *On 4/23/18 a pressure injury had been identified to her left heel. -That pressure injury had been identified 18 days after her admission to the facility. *No documentation to support the physician had been notified and involved with the wound care of the pressure injury until 5/10/18. -That had been 18 days after an area of concern had been identified on the resident's left heel. Refer to F686, finding 1. Surveyor: 2. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support the physician had been notified of: -The incident and injury that had occurred to the resident's left leg on 5/12/18. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had give her for those complaints of discomfort. Refer to F697, finding 1.", "filedate": "2020-09-01"}
{"rowid": 64, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2018-05-16", "deficiency_tag": 880, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "4XMM11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure infection control practices and protocols were followed when providing: *Personal care for two of seven sampled residents (44 and 52) by two of two certified nursing assistants (CNA) (A and B). *Foley catheter care for one of one sampled resident (4) by one of one CNA (A). Findings include: 1. Observation on 5/15/18 at 11:48 a.m. of CNAs A and B during personal care for resident 52 revealed: *He had been laying in his bed and was ready to get up for dinner. *They had sanitized their hands and put on a clean pair of gloves. *With those gloves on they had: -Pushed a mechanical transfer lift over to his bed. -Adjusted his covers and clothes to expose his upper and lower body. -Removed his soiled incontinent brief. *CNA B had: -Assisted the resident to lay on his right side. -Retrieved and opened a package of wet wipes. -Taken several wet wipes out of the package and cleansed his bottom with them. --He had been incontinent with a small amount of bowel movement. -Not removed her soiled gloves and washed/sanitized her hands after performing perineal care for the resident. *CNA A had: -Opened the top drawer of his bedside stand and removed a tube of barrier cream and bottle of powder. -Taken a small amount of barrier cream from the tube and applied it to his bottom. -Opened the bottle of powder and sprinkled some on his bottom over the barrier cream. -Removed her gloves and without washing/sanitizing her hands put on a clean pair of gloves. *With those gloves on they had: -Put a clean incontinent brief on the resident. -Placed a sling underneath of him, pulled the mechanical lift closer to the bed, and attached it to the sling. *They both had assisted the resident out of his bed and into his wheelchair with use of the mechanical lift. *At that time they both removed their soiled gloves and washed their hands. 2. Observation on 5/15/18 at 1:30 p.m. of CNAs A and B during personal care for resident 44 revealed: *The resident had been sitting in a Broda w/c and was ready to lay down on her bed. *They had washed their hands and put on a clean pair of gloves. *With those gloves on they had: -Used a mechanical lift to transfer her from the w/c onto the bed. -Pulled down her pants and removed her soiled incontinent brief. *With those same gloves CNA A had: -Opened the top drawer on the bedside table. -Retrieved a package of wet wipes, a tube of barrier cream, and a package of skin prep swabs. *CNA B had: -Retrieved several wet wipes from the package and cleaned the resident's bottom. -Opened the tube of barrier cream and applied some to her bottom. *CNA A had: -Retrieved several wet wipes from the package and cleaned her perineal area. -Changed her gloves without sanitizing/washing her hands. *They had removed a pressure relieving boot and sock from the resident's left foot. -That pressure relieving boot had been sitting on a soiled footrest attached to the w/c. -There had been a black colored area on the resident's left heel. *With the same gloves that CNA B had used to: -Handle/move a mechanical lift and w/c. -Transfer a resident into her bed. -Remove clothes and an incontinent brief. -Clean the bottom of a resident. -Remove a pressure relieving boot and sock from a foot. *CNA B had proceeded to: -Open the package containing skin prep swabs. -Get a skin prep swab from that package. -Wipe the skin prep over the wound on the resident's left foot. -Put the resident's sock and pressure relieving boot back on. *They finished positioning the resident in her bed. *At that time they both removed their soiled gloves and washed their hands. 3. Observation on 5/16/18 at 8:00 a.m. of CNA A during Foley catheter care for resident 4 revealed: *The resident had: -Been laying in his bed. -A Foley catheter in place with a collection bag attached to it, and it was hanging from the bedframe. *The CNA washed her hands and put on a clean pair of gloves. *With those gloves on CNA A had touched multiple unclean surfaces prior to the catheter care. *Those surfaces had been: -A plastic basin containing a Foley catheter leg bag. -A package of wet wipes, a bottle of perineal cleansing spray, and several packages of alcohol wipes. -A clothes hanger with a shirt on it. --She showed it to the resident to ensure it was the shirt he had picked out to wear for the day. -The bed covers to expose the catheter and perineal area. *With those soiled gloves on CNA A: -Detached the Foley collection bag from the catheter tubing and attached the Foley catheter leg bag to it. -Retrieved several wet wipes and cleaned the front perineal area and Foley catheter insertion site. -Cleaned the catheter tubing in an upward and downward motion. *The CNA removed her gloves, washed her hands, and assisted the resident to get dressed for the day. Interview on 5/16/18 at 8:29 a.m. with CNA A regarding the above observations revealed she: *Had not recognized the processes above as unsanitary until being reviewed with the surveyor. *Agreed the processes above could have created the potential for cross-contamination of germs to the resident. *Had not recognized the outside surfaces of all the items touched above would have been considered unclean. *Confirmed her hands should have have been washed/sanitized between glove change. *Could not remember the last time the staff had been trained on proper protocols and processes for personal and Foley catheter care. 4. Interview on 5/16/18 at 3:40 p.m. with the director of nursing and administrator confirmed: *The above observations had not been completed in a sanitary manner. *There was the potential for cross-contamination of germs to have been transmitted to those residents. *Hands should have been washed/sanitized between glove change. *With those processes used above the residents had been at risk for facility acquired infections. Review of the provider's (MONTH) (YEAR) Hand Hygiene policy revealed: *Hand hygiene was the single most important procedure for the control of infection. It was a critical component of patient and employee safety. *Policy: -Wash hands with system approved soap and water when hands are visibly soiled with blood or other body fluid. -Hand hygiene with Alcohol Hand Rub (antisepsis) after contact with inanimate objects in the immediate vicinity of the patient (resident) and after glove removal. Review of the provider's 2007 Catheter Care policy revealed: *Purpose: To prevent infections. *Procedure: Wash the catheter from the meatus down the tube about three inches.", "filedate": "2020-09-01"}
{"rowid": 65, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 166, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "Based on interview, record review, and grievance process review, the provider failed to ensure resident council concerns were followed-up on and resolutions were taken back to the resident council. Findings include: 1. Interview on 5/23/17 at 10:00 a.m. with a group of residents revealed: *They had concerns with chicken being served all the time. *The men's bathroom on first floor was not handicap accessible. -The women's bathroom had not been turned into a unisex bathroom. *Laundry items went missing and were not returned. *One resident was still missing an honor flight shirt. *Those concerns had been brought up at resident council meetings. Review of the resident council minutes from 11/28/16 through 4/24/17 revealed: *On 11/28/16 under other business was problems with getting laundry back. -On 12/29/16 under other business it stated Laundry knows they are working on it. -On 1/26/17 there had been no further documentation on the laundry concern. *On 2/27/17 they had requested less chicken. -There had been no further documentation on the laundry concern. *On 3/27/17 they had requested less chicken and stated the men's bathroom on first floor was not accessible. -Two grievance forms had been completed. --The first grievance form had been about having too much chicken. ---The resolution had stated they acknowledged chicken was on the menu way to close together and frequently. ---They would look at menus and change to summer cycle 6/1/17. ---There had been no signatures regarding who had filled out the form. --The second grievance form had been about the men's bathroom. ---The resolution had been to use the women's bathroom, and the sign would be changed to unisex. ---There had been no signatures regarding who had filled out the form. *On 4/24/17 there had been no documentation regarding the follow-up to the menus or the men's bathroom. Surveyor: Interview on 5/24/17 at 8:44 a.m. with the social worker regarding missing clothing items revealed: *Residents were to tell the nursing staff who in turn were to tell the social worker. *She would send out a notice to all departments when an item was reported missing, and she looked in the linen rooms on each floor. -The laundry was done by floors, so any unmarked items were returned to the floor it came from. *They tried to replace an item if it was lost and not found. *She was unaware of listings of missing items that were on the back of linen room doors. *There was no policy on how to handle missing laundry. *She had not been aware of the missing laundry items reported during the group meetings. *She agreed there was no system to ensure all missing items got reported to her. Surveyor: Interview on 5/24/17 at 9:30 a.m. with the activities director revealed: *She was unaware the other department heads could attend the resident council meetings. *She was unsure why the women's bathroom sign had not been changed to say unisex. *She stated she had completed the 3/27/17 grievance forms. -She had not signed the forms. -She had turned the forms into the administrator for review. -There had been no documentation the administrator had seen the forms. -She knew getting back laundry was an issue but was not sure what the laundry department was doing to make it better. Interview on 5/24/17 at 10:40 a.m. with maintenance staff person H regarding the men's restroom by the main dining room on the 100 floor revealed he: *Agreed the men's bathroom was not handicapped accessible. *Had not seen a work order regarding the changing of the women's rest room to a unisex bathroom and the closing of the men's bathroom. Review of the provider's (MONTH) (YEAR) Grievance process revealed: *If residents had an issue with their rights being violated they were to contact the nursing coordinator or the social worker. -The director of nursing would have been contacted and the issues should have been resolved within twenty-four hours. *The residents had the opportunity to file a grievance if they felt a problem was not resolved. -The residents were to contact in writing or per telephone the administration office or the vice president of outcomes and service excellence. -A written response was to have been expected within forty-five days upon receipt of the grievance detailing the steps taken to investigate the grievance.", "filedate": "2020-09-01"}
{"rowid": 66, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 280, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to update care plans to reflect the current needs for 5 of 13 sampled residents (6, 7, 9, 10, and 13). Findings include: 1. Review of resident 9's complete medical record revealed: *He was admitted on [DATE]. *He received blood thinning medication. *He had [DIAGNOSES REDACTED]. *No skin diagram and progress note was found in the skin documentation book. Review of resident 9's 5/16/17 wound care nurse's recommendations revealed: *Zinc oxide paste currently being used seems to have difficulty adhering to the open sores of the sacral area. *[MEDICATION NAME] paste to be used in place of zinc oxide. A thick layer should be placed several times a day and with every incontinent episode. *Cleanse the top layer of the [MEDICATION NAME] but do not attempt to clean off all of the [MEDICATION NAME] prior to every re-application. *An alternating low air loss mattress. *A pressure redistribution cushion to his wheelchair. *Resident to be up to the chair for meals and therapy, otherwise in bed to relieve pressure off his sacrum. *Frequent repositioning is also necessary as he is quite immobile. *Heel lifts are in place to bilateral feet. *Pillows to be used to off-load pressure from the heels and for repositioning, at least every two hours, with micro turns in between. Review of resident 9's 5/11/17 care plan revealed: *A problem area of Skin integrity. *A goal of Skin integrity - improve. *The following interventions: -Heel protectors at all times. -[NAME] hose should be on during the day and removed at night. -Pressure redistributing cushion in chair. -Pressure redistributing mattress. -[MEDICATION NAME] is to be reapplied with every incontinent episode - thickly so that covers the complete area that is open. Foaming wash needs to be used to cleanse buttock - do not scrub the [MEDICATION NAME] off. -Monitor deep tissue injury to sacrum area daily until healed. -Braden Scale LTC (long term care). -Skin Basic Assessment LTC. Observation on 5/23/17 at 10:24 a.m. with certified nursing assistants (CNA) A and B with resident 9 revealed: *The CNAs had transferred the resident with the Hoyer lift from his wheelchair to his bed. *He was incontinent of bowel and bladder. *After they had cleansed the sacral wound a thick layer of barrier cream was applied. *He was repositioned on his left side and supported with pillows. *His bilateral heel protectors were on. *No [NAME] hose were on his legs. *Lower legs had [MEDICAL CONDITION]. Observations on 5/23/17 of resident 9 at the following times revealed: *At 12:05 p.m. he was sitting up in his wheelchair. *At 2:00 p.m. he was on his back in bed with heel protectors on. *At 4:30 p.m. his position was unchanged. Interview on 5/23/17 at 10:50 a.m. with CNA A regarding what was to be done for resident 9 for his skin issues revealed: *He was to lie down as often as possible. *The barrier cream was to be globbed on. Interview on 5/23/17 at 4:20 p.m. with licensed practical nurse (LPN) D regarding resident 9's skin assessment revealed: *A head to toe assessment was done on admission and weekly. *If consulted the wound care nurse would assess skin, recommend treatment, and do dressing changes. Interview on 5/24/17 at 8:15 a.m. with registered nurse (RN) [NAME] regarding resident 9's skin assessment revealed: *It was done weekly during bath time. *Documentation of all skin irregularities were done on the skin diagram sheet along with a progress note in the electronic medical records. Interview on 5/24/17 at 8:30 a.m. with CNA C regarding resident 9's skin integrity interventions revealed: *He was to be checked for incontinence of bowel and bladder. *His sacral wound was to be cleansed without rubbing. *He was to be repositioned every couple hours. *Lotion was to have been applied to dry skin. 2. Review of resident 13's complete medical record revealed she: *Was admitted on [DATE]. *Had [DIAGNOSES REDACTED]. Review of resident 13's 4/10/17 minimum data set assessment (MDS) revealed she preferred the following activities: *Listen to music. *Keep up with the news. *Do things with groups of people. *Do favorite activities. *Participate in religious services. Review of resident 13's 5/22/17 care plan interventions for activity involvement revealed: *A problem area of Activity Involvement potential for decline in activity involvement related to NH (nursing home) stay. *A goal of Activity Involvement - Maintain. *The following interventions: -Assess for changes in support - LTC. -Evaluate family support. -Spiritual assessment - LTC. Spiritual care to visit routinely. Chaplain available upon request. -Restorative evaluation - LTC. -Current lifestyle - LTC. Observation on 5/22/17 at 4:15 p.m. of resident 13 during initial tour revealed she was in her wheelchair in front of her television that had music playing on it. Observation on 5/24/17 at 7:30 a.m. of resident 13 revealed she was in bed and music was playing on her television. Interview on 5/24/17 at 4:05 p.m. with the administrator and director of nursing (DON) regarding care plans revealed: *They agreed the above residents' care plans were not complete. *They would have expected all residents' care plans to have been individualized to reflect the current needs of each resident. 3. Review of resident 7's medical record revealed: *She had been admitted on [DATE]. *She had been started on [MEDICATION NAME] on 4/5/17 due to wandering behaviors. *She had been admitted into Hospice care on 4/12/17. Review of resident 7's 4/26/17 care plan revealed: *There were no non-pharmacological interventions for her behaviors. *The integrated Hospice plan had not been documented on the care plan. Interview on 5/24/17 at 4:45 p.m. with the administrator and the director of nursing regarding resident 7 revealed: *There had been no documentation on the care plan regarding her wandering behavior. *They had not attempted or documented any non-pharmacological interventions before starting the [MEDICATION NAME]. -They agreed those should have been on the care plan. *They agreed the specific responsibilities regarding being on Hospice had not been included in the care plan. 4. Interview on 5/23/17 at 11:00 a.m. with resident 10 revealed: *She had a stroke and was admitted into the transitional care unit on 1/7/16. *She then transitioned into the long term care side of the facility. *She wanted to be in an assisted living center instead of in the nursing home. *She bathed herself and took care of herself. Review of resident 10's 4/10/17 MDS assessment revealed she was independent with all activities of daily living. Review of resident 10's 1/26/17 care plan revealed there had been no interventions or goals for discharge planning. Interview on 5/24/17 at 11:30 a.m. with the Social Worker Associate and the administrator regarding resident 10 revealed: *They had not been actively doing discharge planning with the resident. *They both knew she had wanted to live somewhere else. *They stated they felt her blood sugars were unpredictable. *They had no documentation they had attempted to educate her about her blood sugars. Review of the provider's 9/13/16 Care Plan policy and procedures revealed: *It is the philosophy of Avera Longterm Care to communicate effectively with all staff providing care for our residents. By ensuring a standardized care plan process we are ensuring staff is getting the needed information for resident's care. *Resident's Plan of Care: The Meditech Plan of care includes all medications, physician's orders [REDACTED]. *Interdisciplinary team in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, will develop measurable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment, the MDS 3.0. *Resident care plans are generated on the computer and updated by designated staff. *The care plan must reflect intermediate steps for each outcome objective if identification of these steps will enhance the resident's ability to meet his/her objectives.", "filedate": "2020-09-01"}
{"rowid": 67, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 284, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to implement discharge planning for one of one sampled resident (10) who was independent and wanted to move to an assisted living center. Findings include: 1. Observation and interview on 5/23/17 at 11:00 a.m. with resident 10 revealed: *She walked without a walker or assistive device. *She was well groomed. *She stated she gave herself her own shower. *She wanted to move into an assisted living center. *She had a microwave in her room, and they had taken it away from her. -She wanted the microwave back. *She liked to play cards. *She liked to walk. Surveyor: Observation and interview on 5/23/17 at 11:24 a.m. with resident 10 revealed: *Licensed practical nurse (LPN) F had taken her blood glucose and it had been 113. *LPN F had asked her if she wanted her noon dose of insulin. *Resident 10 replied she did not need her noon dose of insulin. *LPN F explained that resident 10 makes her own decisions if she wants her insulin according to her blood sugars. Surveyor: Review of resident 10's 1/26/17 care plan revealed there were no goals or interventions for discharge planning. Review of resident 10's medical record revealed she was her own power of attorney and made her own decisions. She had been admitted on [DATE]. Review of resident 10's 9/28/16 and 1/6/17 social services notes revealed: *She had stated her desire to move out of the facility and into the community. *There had been no documentation regarding discharge planning that had occurred following those requests. *On 1/6/17 Section Q she really wanted to return to the community but her family think it isn't feasible at this time due to meds and diabetes. Review of resident 10's 10/19/16 care conference note revealed she wanted to move out. She was interested in the independent living center in Chamberlain. It stated she and her daughter were looking into it. There had been no documentation in regards to what the staff were doing for her discharge planning. Review of resident 10's 7/20/16 care conference note revealed: *There was no discharge planning occurring for her. *They had Discussed her tendency to have low blood sugars and encouraged her to speak with her doctor when she asked about 'a pump' which she has heard other people have sometimes. *There had been no documentation regarding what staff were assisting her with and if the pump would have helped her being able to move out of the facility. Review of resident 10's 4/18/17 care conference note revealed she wanted to move out of the facility. They were not doing discharge planning, because the family did not want it. Interview on 5/24/17 at 11:30 a.m. with the social worker associate (SWA) and the administrator regarding resident 10 revealed: *The SWA had not been actively discharge planning for her. *The resident had blood sugars that sometimes became very low. *They had not contacted the physician regarding the possibility of a pump. *The last documented attempt for discharge planning they located was on 4/8/16. *The family had not agreed with her moving out. *They both agreed she was capable of making her own decisions, but the family did not agree with them. *They stated she wanted to live in Pierre, and the assisted living center would not take Medicaid. -That had contradicted the above information that she would move to Chamberlain. *They had no other documentation the resident had not wanted to live in any other assisted living center. *They had found an application completed by the SWA for Money Follows the Person, but it had not been dated. Review of the provider's (MONTH) (YEAR) Discharge Planning policy revealed: *A discharge planning high risk screening, evaluation, and care plan should have been completed. *The professional medical social services staff will initiate the assessment process for each identified patient (resident). *An acceptable reason that Social Services cannot be provided after an identification of need is made is that the patient refuses. *Exceptions to refusal include crisis room patients and suspected abuse cases. *Attempts made to reach a patient or family, determinations made that discharge planning is not clinically indicated yet, other clinical reasons that active discharge planning is not possible, must be stated in the documentation as it is a part of the assessment and treatment planning process.", "filedate": "2020-09-01"}
{"rowid": 68, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 329, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to attempt non-pharmacological interventions and have a documented justification for starting an antipsychotic medication for one of one sampled resident (7). Findings include: 1. Random observations on 5/23/17 from 7:55 a.m. through 5:00 p.m. of resident 7 revealed she had been in bed. Surveyor: Interview on 5/23/14 at 2:15 p.m. with resident 7's son revealed: *His mother has been feisty all of her life. -He had not seen a change in his mother's personality concerning her cooperation with staff. *He visited often, as he worked nearby. *She recognized him and had called his name. Surveyor: Review of resident 7's medical record revealed: *She had been admitted on [DATE]. *She had been started on [MEDICATION NAME] on 4/5/17 due to behaviors. *She had been put into hospice care on 4/12/17. -They had requested the [MEDICATION NAME] be discontinued on that date. -The physician had not discontinued it. *On 5/3/17 the [MEDICATION NAME] had been discontinued. Review of resident 7's interdisciplinary notes revealed: *On 3/31/17 Is combative with cares at times. *On 4/1/17 Once she had it in her mouth she put a tissue up to her mouth and removed the medications. 'I am not going to take this[***]' *On 4/2/17 Spit out most of the medication at 1700 and refused hs (bedtime) medications and became very vocal. *On 4/2/17 Found during the night to have gotten up independently and walked across the hall and sit on another residents bed. *On 4/3/17 Angry with the pressure of the BP (blood pressure) cuff and then pushes me away and will not let me continue my assessment. *There had been no other documentation regarding behaviors or what non-pharmacological interventions had been attempted. Review of resident 7's 4/6/17 physician's visit note revealed: *The patient has not voiced complaints, is minimally verbal. *Staff reports that she has become occasionally belligerent in the evenings. *She will not cooperate with transfers and requires the assistance of two. *Yet at 10:00 p.m. in the evening typically she will get up and start walking the halls looking for a bathroom. *She is alert enough to take her TABS (personal alarm) device off and staff is concerned that she may wander and leave the building. *She sometimes fights staff when it comes time to reorient her, the staff finds that she is not always re-orientable. *The patient (resident) voices no complaints, very hard of hearing and quite demented. *Late-stage dementia with sundowning phenomenon. The patient is at risk of harming self. Start [MEDICATION NAME] 0.5 mg at hs and we will monitor for effect. -There had been no documentation to support she had been at risk for harming herself. *There had been no documentation of non-pharmacological interventions attempted or other medications attempted prior to starting [MEDICATION NAME]. Review of resident 7's 1/26/17 care plan revealed there were no individualized behaviors listed. There were no non-pharmacological interventions listed for her behaviors. Interview on 5/24/17 at 4:45 p.m. with the director of nursing revealed: *There had been no other documentation regarding resident 7's behaviors justifying the need for the [MEDICATION NAME]. *She had not liked the order and was not sure why something else had not been attempted. *She agreed non-pharmacological interventions should have been attempted prior to starting the [MEDICATION NAME]. Review of the provider's (MONTH) (YEAR) Psychopharmacological Medications policy revealed: *Inadequate indicators for the use of antipsychotics were: -Wandering. -Poor self care. -Restlessness. -Impaired memory. -Mild anxiety. -[MEDICAL CONDITION]. -Unsociability. -Inattention or indifference to surroundings. -Fidgeting. -Nervousness. -Uncooperativeness. -Verbal expressions or behavior that is not due to the conditions listed and do not represent a danger to residents or others.", "filedate": "2020-09-01"}
{"rowid": 69, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "Based on observation, interview, and policy review, the provider failed to ensure cleanliness of 3 of 4 refrigeration cooler fans and failed to ensure food sanitation practices were followed when food was being stored in 1 of 1 dry storage areas in the kitchen pantry. Findings include: 1. Observation on 5/22/17 at 4:13 p.m. of 2 of 2 walk-in produce and dairy coolers revealed several opened, undated, and unlabeled food items and several dirty cooler fans had not been maintained in a clean and sanitary manner: *Small container of potato salad. *A bag of lettuce. *A bag of spinach. *One dirty fan cover in the produce cooler was covered with a black fuzzy substance. *Two dirty fan covers in the dairy cooler were covered with a black fuzzy substance. 2. Observation on 5/22/17 at 4:40 p.m. of the dry storage area in the kitchen pantry revealed a large bag of panko bread crumbs was opened. However it was not in a storage container and dated. 3. Interview on 5/23/17 at 10:50 a.m. with the supervisor of food services confirmed: *The following food items should have been labeled and dated. -The container of potato salad. -The bag of lettuce. -The bag of spinach. *Food items should have been stored properly. *Cooler fans should have been on a cleaning schedule. Interview on 5/24/17 at 2:45 p.m. with the director of nursing, registered dietician, dietary manager confirmed: *All opened food that was not in the original container should have been labeled and dated. *All prepared food should have been labeled and dated. *Cooler fans should have been on a routine cleaning schedule. Review of the provider's undated POLICY CLEANING FANS AND CEILING IN WALK IN COOLERS AND FREEZERS revealed: *How to clean the fans. *Did not list the schedule for cleaning. Review of the provider's revised (MONTH) (YEAR) Food Storage policy revealed: *Dry storage foods must be covered and dated if container was opened and partially used. *All foods should have been covered, labeled, and dated with labels on the sides of the containers, if the food was not stored in its original container. All opened products should have been dated. Review of the provider's revised (MONTH) (YEAR) Leftover Use and Shelf Life of Potentially Hazardous Foods policy revealed: *Ready-to-eat potentially hazardous food prepared and packaged by a food processing plant shall be marked to indicate the date by which the food must be consumed. *The product must be consumed or discarded seven days after the original package is opened.", "filedate": "2020-09-01"}
{"rowid": 70, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "Based on observation, interview, record review, and policy review, the provider failed to ensure nebulizer equipment had been cleaned according to the provider's policy for three of three residents (4, 18, and 19) that had received breathing treatments randomly observed. Findings include: 1a. Observation on 5/23/17 at 11:00 a.m. with resident 18 revealed: *The nebulizer equipment was fully assembled with a small amount of clear liquid in the medication chamber. *Medication was added to the medication chamber, without removing the small amount of clear liquid, by licensed practical nurse (LPN) F. b. Observation on 5/24/17 at 7:52 a.m. with resident 19 revealed: *The nebulizer mask and medication chamber was assembled and laying on the bedside stand. *There was a small amount of clear liquid in the chamber, prior to the medication being added to the chamber. *Medication was added by registered nurse (RN) E. c. Observation on 5/24/17 at 11:15 a.m. with resident 4 revealed: *His nebulizer was fully assembled with a small amount of a clear liquid in the medication chamber. *Medication was added to the chamber, without removing the small amount of clear liquid, by LPN F. d. Interview on 5/24/17 at 8:45 a.m. with LPN [NAME] revealed: *The night staff cleaned the nebulizer equipment every three days. *The equipment should have been replaced every month by night staff. -Including mouth piece or mask, medication chamber, and tubing. *These dates were noted on the treatment plan. Interview on 5/24/17 at 3:35 p.m. with the director of nursing (DON) revealed: *She would have expected the chamber and mouth piece or mask to have been disassembled and rinsed after every use. *Then should have been allowed to air-dry on a towel in the resident's room. Interview on 5/25/17 at 2:15 p.m. with CNA G revealed: *She had not seen the nebulizer equipment air drying in residents' rooms. *Usually they were placed on the bedside table fully assembled. Review of resident 4's medication administration record (MAR) revealed to clean the mask and nebulizer tubing every three days. Review of resident 18's MAR revealed to clean tubing and mouthpiece every three days. Review of resident 19's MAR revealed to soak nebulizer set up in dish soap, vinegar, and water, every 72 hours. Review of the provider's undated Nebulizer Cleaning policy revealed: *Rinse nebulizer mask with water every night after the last treatment. *Allow mask and medication component to air dry overnight. -Do not dry by hand as that could have left lint. *No mention of the tubing.", "filedate": "2020-09-01"}
{"rowid": 71, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2017-05-24", "deficiency_tag": 456, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "43OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and manufacturer's instructions, the provider failed to ensure: *Two of three whirlpool baths (100 and 300 floors) were maintained in working order, with all jets covered, on a regular basis. *Eight of eight EZ Stand lifts shared and moved between the three floors were maintained on a monthly basis with safety clips/safety tabs in place as per manufacturer's instructions. Findings include: 1. Observation on 5/22/17 from 4:25 p.m. through 5:45 p.m. identified: *Three EZ Stand lifts on the 100 floor had: -Combination metal safety clips and rubber tabs on all three lifts on the floor. -Rubber tabs were not positioned to hold the lift sling loops in place. *The whirlpool tub jets were missing five of twelve inserts and nine of twelve covers. 2. Observation on 5/23/17 at 9:00 a.m. on all three floors found: *A total of eight lifts (100, 200, and 300 floors) had the same above observations as were made on the 100 floor. *The whirlpool tub on the 300 floor was missing seven inserts and ten covers. 3. A group meeting with residents on 5/23/17 at 10:00 a.m. revealed the jets had not been working on the 100 floor whirlpool. 4. Interviews on 5/24/17 between 9:00 a.m. and 9:20 a.m. with certified nursing assistants I and J on the 100 floor revealed the whirlpool jets worked if the tub was half filled with water but not if the tub was full of water. Interview on 5/24/17 at 10:40 a.m. with the maintenance staff person H revealed: *He believed biomedical engineering was maintaining the lifts. -After calling biomedical engineering it was found they only maintained the electrical components not the lift itself. *There was no routine or preventative maintenance of the lifts being done. *He had not been informed of the whirlpool tub jets on the 100 and 300 floors missing inserts and covers. -Nursing staff were to notify the maintenance department. *He had not been informed of the whirlpool jets not working on the 100 floor. -Nursing staff were to notify the maintenance department. Review of the EZ [MEDICATION NAME] Stand manufacturer's instructions dated 6/27/03 identified the lifts were to be maintained monthly. The whirlpool manufacturer's instructions were requested of maintenance staff person H on 5/24/17 at 11:15 a.m., but were not received before the end of the survey.", "filedate": "2020-09-01"}
{"rowid": 72, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2019-08-07", "deficiency_tag": 550, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ILL611", "inspection_text": "Based on observation, interview, record review, and review of the Resident Information Handbook, the provider failed to ensure one of one sampled resident (52) was dressed in a dignified manner. Findings include: 1. Observation on 8/5/19 at 5:45 p.m. of certified nurse aide (CNA) G and CNA H revealed: *They had transferred resident 52 with a mechanical lift. *The backside of the resident's pants had been cut from the center of the waistband to the crotch. *CNA G had stated that made it easier to remove the resident's pants when she was toileted. *CNA G had given the resident two plastic clips to secure her shirt to the pants after the lift was completed. Interview on 8/5/19 at 5:52 p.m. with resident 52 regarding those pants revealed: *She had stated I hate it. *The modified pants made her feel self-conscious. *She said staff had told her they were working on a modification to make the cut pants more discreet. -She had been told that over a month ago. Interview on 8/6/19 at 2:15 p.m. with resident 52 revealed: *She had gone into the community today and had been dressed in a regular pair of pants. *She was re-dressed upon returning to the facility into a pair of cut pants. -The cut pants were not her own and had been provided to her by the facility. *She had stated They (the pants) keep falling down. -The plastic clothespin and another plastic clip she had used to keep her pants up were her own. Interview on 8/7/19 at 1:20 p.m. with the social services designee revealed: *She was aware of resident 52's dislike of the cut pants. -That had been discussed at her 7/3/19 interdisciplinary care conference. -She had thought a staff member was working on a modification to the pants. *She was unaware the resident had been using her own plastic clothespin and clip to secure her top to her pants. -She had thought the clothespin and clip were appropriate to use if it works. *She was unaware of the resident's concern for skin exposure when she wore the cut pants. -She had stated I don't know if it looks so good dignity wise and if we could find something better that would be good. Review of resident 52's medical record revealed her Brief Interview for Mental Status assessment score was fifteen indicating her cognition was intact. Review of the 7/3/19 care conference progress note revealed: *Resident Comments: -Wants to wear her own un-modified pants, but now that she is unable to stand to bear weight, must use the maxi lift and has been unwilling to roll side to side, has been trialing split pants but she doesn't like these; we are willing to modify these for her with a strap/connector, but she still wants to wear unmodified pants. A Dignity policy was requested on 8/7/19 at 11:30 a.m. from the administrator, however she stated the facility did not have one. Review of the provider's undated Resident Information Handbook revealed: *Emotionally: -The daily goal of our nursing facility is to encourage residents and patients to live at their highest level of physical, emotional, and mental capabilities. Respect for the dignity of the human person is basic to our philosophy of care.", "filedate": "2020-09-01"}
{"rowid": 73, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2019-08-07", "deficiency_tag": 656, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ILL611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to develop and revise individual care plans to reflect the current needs for 2 of 14 sampled residents (3 and 31). Findings include: 1. Multiple random observations on 8/6/19 from 9:00 a.m. through 5:30 p.m. and again on 8/7/19 from 8:30 a.m. through 2:00 p.m. of resident 3 revealed he: *Sat in his slightly reclined Broda chair. *Had pink foam boots on both heels. *While he sat with the pink foam heel protectors on his heels had been firmly pressed against his chair. That would have offered no pressure relief or off loading for his heels. *Both of his legs were contracted. *There had been no protection for his lower legs and knees for pressure relief. Review of resident 3's revised 8/2/19 care plan revealed: *A problem area stated: Skin integrity. -The goal for the above focus area regarding the resident's heels and legs had been: Maintain. -Interventions for the above had been: --Heel protectors on while in bed and/or offload heels on pillows. --Place cushion/pillow between knees to provide protection from his knees pressing on each other. Interview on 8/7/19 at 4:00 p.m. with the administrator and director of nursing regarding resident 3 revealed they: *Confirmed the resident had a right heel pressure ulcer. *Agreed the pink foam boots did not offer pressure relief when they had been constantly pressed on the foot and leg area of the Broda chair. *Agreed the resident was to have had a cushion and pillow between his knees for preventative pressure relief. Review of the provider's last revised (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed its purpose had been: *To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers; to systematically assess and document skin risk factors; to implement skin-protection components of care, and to provide appropriate treatment when indicated. *Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. 2. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She was on a renal diet with a 1500 milliliter fluid allowance per day. Observation on 8/6/19 at 2:22 p.m. and at 4:30 p.m. of resident 31 revealed: *She was sitting on her bed watching television. *Her room had a foul odor. *There was a moderate amount of feces on the floor next to her bed in front of the garbage can. *Had witnessed her throw an empty paper package on top of the feces on the floor. Interview on 8/6/19 at 2:58 p.m. with registered nurse (RN) I regarding resident 31 revealed: *She often had feces on the floor in her room. *She would also throw garbage and paper on the floor in her room. Review of 6/10/19 the registered dietician's nutrition information note regarding resident 31 revealed: *Her husband had brought food in to her including fluids. *Both the resident and her husband had been educated on dietary recommendations. *Husband just wants her to be happy, and she agrees with this. Review of the last reviewed 6/27/18 care plan for resident 31 revealed no behaviors and non-compliance with diet had not been identified. Review of a 7/18/19 nurses note regarding resident 31 revealed: *The [MEDICAL TREATMENT] center had sent nutrition education with the resident after her [MEDICAL TREATMENT] treatment. *The nurse had asked her husband if he wanted to review the education. -He had not reviewed the information. -He told the nurse that the resident was going to do what she wanted. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31's care plan revealed: *She had agreed the non-compliance with diet and fluid allowance and the behaviors such as defecating on the floor should have been on the care plan. *She had not put the behaviors on the care plan, because she did not have interventions to add that would help decrease the behavior. A care plan policy was requested on 8/7/19 at 11:30 a.m from the administrator. A policy for Baseline Care plans was received but not for care plans. The administrator stated they did not have one.", "filedate": "2020-09-01"}
{"rowid": 74, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2019-08-07", "deficiency_tag": 698, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ILL611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the provider failed to ensure communication between a [MEDICAL TREATMENT] center and the provider was documented, that nursing staff were assessing the resident for change of condition, and they were following physician orders [REDACTED]. Findings include: 1. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She had an arteriovenous (AV) fistula place on 7/31/19. *[MEDICAL TREATMENT] post-assessment had not been completed since 7/18/19. Review of resident 31's 7/31/19 nurses note revealed: *She had returned from an appointment for the AV fistula placement. *The dressing was to be removed after forty-eight hours. *She was to do stress ball exercises twenty times every hour while awake. Review of resident 31's last reviewed 6/27/18 care plan revealed a [MEDICAL TREATMENT] post assessment was to be completed on [MEDICAL TREATMENT] days. Interview on 8/7/19 at 10:14 a.m. with registered nurse (RN) B regarding resident 31 revealed: *An assessment was to be done in the electronic medical record when she returned from [MEDICAL TREATMENT]. -She did know how to find and complete assessment. -She did not know where the assessment was to review it after it had been completed. *The resident had a fistula placed a couple days ago on 7/31/19. Interview on 8/7/19 at 10:23 a.m. with resident 31 and her husband revealed that they did not know if a post-[MEDICAL TREATMENT] assessment had been done after her [MEDICAL TREATMENT] treatments. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31 revealed the [MEDICAL TREATMENT] post-assessment should have been completed by a nurse after each [MEDICAL TREATMENT] procedure. Interview on 8/7/19 at 3:19 p.m., at 3:28 p.m., and at 4:19 p.m. with the assistant director of nursing regarding resident 31 revealed: *She had went to an appointment on 7/31/19 for afistula and had returned with new physician orders [REDACTED]. -She could not find the physician orders [REDACTED]. -They would not have documented that stress ball exercises had been completed. *When the resident returned from [MEDICAL TREATMENT] appointments the [MEDICAL TREATMENT] center would send a communication sheet back with her. -The communication sheet had before and after [MEDICAL TREATMENT] run weight and vital signs on it. It would have also contained any new orders. -The nurse reviewed the sheet upon return. -The weights were recorded in the electronic medical record, and then the sheet was shredded. *The resident's treatment record was requested during the interview, but it had not been provided by the end of the survey. *Requested the policy on [MEDICAL TREATMENT] and assessment post-[MEDICAL TREATMENT] treatment. -She stated the provider did not have a policy on that. *She had done a training on [MEDICAL TREATMENT] with staff. -The training material was requested during the interview, but it had not been provided by the end of the survey. Interview on 8/7/19 at 3:43 p.m. with RN I regarding resident 31 revealed: *When the resident returned from the [MEDICAL TREATMENT] center she looked at the dressing and did an assessment. *She reviewed the communication sheet from the [MEDICAL TREATMENT] center. *After she reviewed the sheet she put it in a file to be scanned into the medical record. *She did not document her assessment. *She did not know about the [MEDICAL TREATMENT] post-assessment that was to be completed.", "filedate": "2020-09-01"}
{"rowid": 75, "facility_name": "AVERA MARYHOUSE LONG TERM CARE", "facility_id": 435034, "address": "717 EAST DAKOTA", "city": "PIERRE", "state": "SD", "zip": 57501, "inspection_date": "2019-08-07", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "ILL611", "inspection_text": "Based on observation, record review, and interview, the provider failed to ensure proper sanitation practices including hair net accessibility, hand sink cleaning, dishwasher cleaning, water line maintenance, and temperature probe calibration had occurred in the nursing home dish room and kitchen. Findings include: 1. Observation and interview on 8/6/19 at 11:05 a.m. with dietary staff person F during the dish room tour revealed: a. Hairnets: *There were no hairnets available in the dish room. -Dietary staff person F had stated those who entered the dish room usually were already wearing a hair covering. b. Hand washing sink: *The white porcelain hand washing sink was a dirty off white and yellowish color. *There were small bits of brown debris stuck inside the sink bowl and its perimeter. -The bits could be removed by scraping them with a fingernail. *The sink drain had a two to three inch ring of orange around it. c. Dishwashing machine: *The top of the machine was covered with a raised off white to light brown crusty substance that could not be removed by swiping a finger across it. *Along the back edge of the dishwashing machine were two separate dark brown areas between six and 10 inches in length and approximately three to four inches in width. -The shape of those areas suggested liquid had sat and dried there. -The hardware along that back edge was crusty with what looked like a lime build-up. *On top and to the front of the dishwashing machine were wash, rinse, and final rinse gauges. -There was a thick hard raised black substance that ran a length of about twelve inches in front of those gauges. d. Dishwashing machine cleaning: *Dietary staff person F had stated he de-limed and thoroughly cleaned the dishwashing machine every other weekend. -He had stated there was no dishwashing machine cleaning schedule. -The dishwashing machine vendor came at the end of each month to assess the condition of the dish machine. e. Dishwashing machine water lines: *There were two water lines visible beneath the area where dishware exited the dishwashing machine. -There were three to four feet sections of covering on those lines that were torn and exposed the insulation. -Those sections would have been uncleanable surfaces. 2. Observation and interview on 8/6/19 at 11:45 a.m. with dietary staff person [NAME] during the kitchen tour revealed: a. Hairnets: *Hairnets were not accessible upon entering the kitchen. -It was necessary to walk through the kitchen near the serving and food preparation areas to get them. -She agreed the hairnets should have been near the hand washing sink at the kitchen entrance. b. Temperature probes: *Dietary staff person [NAME] had stated she calibrated the kitchen temperature probes one time a week. -She was unsure if there was a policy regarding the frequency of temperature probe calibration. 3. Interview on 8/7/19 at 8:15 a.m. with the dietary manager regarding the dish room and the kitchen revealed: *She was aware of the condition of the hand washing sink. -She said the discoloration was related to chemicals in the local water. *She was aware of the lack of cleanliness on top of the dishwashing machine and agreed it should have been taken care of. *She said she had not noticed the torn covering and exposure of insulation on the water line pipes. -She did not believe that had been reported to maintenance. *She did not realize hair nets were not readily accessible in either the dish room or the kitchen but agreed they should have been. *She was uncertain how frequently temperature probes should have been calibrated. *She stated there were cleaning and duty checklists for the dish room and kitchen. Review of the undated, unused dish room cleaning checklist revealed: *Item to be Cleaned: -Clean sinks at end of shift. --That was to be completed daily. -De-lime dishwashing machine/wipe down entire machine. --That was to be completed weekly. *There was an area at the bottom of the checklist for daily supervisor sign-off. Interview on 8/7/19 at 1:30 p.m. and again at 2:30 p.m. with the administrator and the dietary manager revealed: *There were no policies for dishwashing machine cleaning and maintenance or temperature probe calibration. *There was not a dishwashing machine operator's manual. *The dish room and kitchen cleaning and duty checklists had not been reviewed, revised, or implemented since some time in (YEAR).", "filedate": "2020-09-01"}
{"rowid": 76, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 225, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and plan review, the provider failed to thoroughly investigate and have adequate documentation to support findings of an unsubstantiated conclusion of allegations of neglect for two of two sampled residents (1 and 5). Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *She was alert, and oriented to person, with periods of confusion. -She was able to state her needs. *She was bedridden due to her obesity and the number of staff it would have required to safely transfer her. Further review of resident 1's medical record revealed: *12/11/16 nurses note It was brought to nurses attention that resident had been on bedpan indefinite time period. Resident had the indentation in the shape of a bedpan pressed into her skin and the indentation was 1/16 to 1/8 deep and red in appearance. Resident states is left on bedpan for hours at a time but no one believes her and generally happens at shift change. The nurse asked all staff from med aides to CNA's (certified nursing assistants) on each hall if they had placed or assisted another staff member on helping place the resident on bedpan anytime between the hours of 5:30 am to 10:45 am on 12/11/16. All staff answered no. -It was also brought to the nurses attention at the time the bedpan was discovered the CNA (name) stated the Foley catheter had not been emptied and contained 1550 ml (milliliter) at 1045 raising the question if it had been emptied at the end of the night shift. *12/12/16 fax sent to the physician: (Resident name) was on the bedpan for an extended period of time on 12/11. *Review of resident 1's 11/02/16 care plan revealed: Resident was at risk for skin breakdown. Staff were to assist me to change position at least every two hours. Review of the initial report/investigation sent to the South Dakota Department of Health (SD DOH) on 12/11/16 for the above incident of resident 1 revealed: *The resident was incapable of providing an explanation of the event or capable of participating in an investigation. *On 12/11/16 at roughly 1045 AM (10:45 a.m.) (CNA name) notified charge nurse (registered nurse (RN) name) that resident (name) had been on the bedpan for an extended period of time. All day shift were interviewed and all denied that they had placed (resident's name) on the bedpan. Upon initial investigation, it appears (CNA name) placed (resident name) on the bedpan prior to leaving his shift at 0530 (5:30 a.m.). He states that he notified his co-workers of this over the walkie talkie prior to leaving his shift. However, it appears that there was a breakdown in the communication as the oncoming shift reports not hearing this come through on the walkie talkie upon initial assessment of skin on 12/11 there were no issues with skin integrity. Skin assessment conducted 12/12 revealed a reddened area to buttock, not open. Review of the final report with the conclusive summary statement of the facility's investigation regarding resident 1's above incident revealed: *Upon investigation, all CNAs working the day shift on 12/11 state they did not hear (CNA name) over the walkie talkie, communicating that he had placed (resident name) on the bedpan. The charge nurse working the night of 12/11 states he did hear (CNA name) inform his co workers of (resident's name) being on the bedpan, however none of the day shift responded to him. Our investigation shows that (CNA name) had communicated this information to the oncoming shift; however the oncoming shift was not finished with report and did not yet have their walkie talkies on them. Written education has been provided to (CNA name) on not leaving his shift until the residents he places on the bedpan and/or toilet are finished and removed from toileting. Written education has also been provided to (CNAs names) on our repositioning policy and procedure and educated all nursing staff they are not allowed to leave their shift or leave for break while they have residents they put on the bedpan and/or toilet. *Was abuse/neglect allegation substantiated? No. Continued review of the above incident regarding resident 1 revealed the provider's internal investigation revealed: *Resident Interview: At time resident was found: resident told nurse (RN name) that she is left on the bedpan for hours at a time but no one believes her and generally happens at shift change. *Witness Summary: (CNA name) was working on the 400 hall that day. She started her shift at 0530 (5:30 a.m.). It was not reported to her or did she hear on the walkie talkie that resident was on the bed pan. She provided oral care, washed resident's face and combed her hair that morning at approximately 0730 (7:30 a.m.). Resident had this care provided in her bed. Resident did not communicate that she was on the bedpan. (CNA name) passed her hydration at approx. (approximately) 1000 (10:00 a.m.) and again resident did not communicate she was on the bed pan. When (CNAs names) went to reposition her approx. 1045 (10:45 a.m.) they discovered she had been on the bedpan and notified the nurse. *Summary/Outcome of Investigation Findings included a recap of the above findings, and It was determined that day shift did not follow care plan and reposition at least every 2 hours. Interview on 1/31/17 at 3:00 p.m. with the administrator and the director of nursing regarding resident 1 revealed: *It was expected that any staff that placed a resident on a bedpan or in the bathroom was assisted off the bedpan or out of the bathroom before they left their shift. -That had not happened in the above incident. *They confirmed based on the length of time the resident was left on the bedpan, the CNA had not followed the care plan for repositioning the resident every two hours. -That had not occurred in the above incident. *Because of excess weight the resident could probably not feel the bedpan under her which was why she might not have told staff it was there. *They could not explain how they had concluded neglect had not occurred. 2. Review of resident 5's medical record revealed: *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *She was totally dependent on staff for all activities of daily living. Further review of resident 5's medical record revealed: *10/31/16: Resident was back in room after having bath was being transferred with sling and Hoyer lift with assist of 2 to bed when she slipped out of the sling and hit her head. *Fax sent to the resident's physician: Resident was being transferred back to bed from bath chair didn't have sling hooked properly and resident slid out the bottom hitting her head on floor. Review of the provider's final investigation report submitted to the SD DOH 11/2/16 regarding the 10/31/16 incident for resident 5 revealed: *On 10/31/16 at 10:15 AM (resident's name) was back in her room after receiving a bath. She was being transferred with a Hoyer lift, Hoyer lift sling and assist of 2 staff members, (NA's and CNA's names) back into bed when she slipped and fell to the floor. *Conclusive summary statement of facility investigation: After investigating the situation occurred, it was found that (NA name) did not have the bottom of the lift hooked up correctly as the sling being used requires the straps be crossed under the resident's legs before hooking it to the mechanical lift. (CNAs names) stated that (resident's name) slid out of the bottom of the lift and hit her shoulder on the wheelchair pedal and she bumped her head on the floor. *Was abuse/neglect allegation substantiated: No. Continued review of the provider's investigation into resident 5's 10/31/16 fall revealed: (NA and CNA names) were transferring (resident name) from the tub chair to her bed with a sling, Hoyer lift and assist x2 (two staff). (CNA name) was at the top hooking up the lift when (NA name) was on the bottom hooking up the lift. They started to lift her up from her chair to the bed when she slid to the floor. *Witness Summary Page: (CNA name) stated that she had assumed (NA name) had used this type of lift before and that she should have checked to make sure that she was secured in place before starting the lift. -(NA name) states that she has never used this type of sling before. Interview on 1/31/17 at 3:15 p.m. with the administrator and the director of nursing regarding resident 5's fall on 10/31/16 revealed: *The NA had said she had never used that kind of lift before and had only been on the floor a very short time, maybe a week. She was being overseen by the CNA she was working with at the time of the fall. -She was not yet certified as a nurses aide at the time of the incident. *The CNA should have verified the NA had done everything correctly. -She had not done that. *They could not explain how they determined neglect had not occurred since the CNA had not provided appropriate oversight of the new NA hooking up the Hoyer sling. 3. Review of the provider's (MONTH) (YEAR) Abuse Prevention Plan revealed Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.", "filedate": "2020-09-01"}
{"rowid": 77, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the provider failed to ensure residents' dignity and respect was maintained during the removal of a deceased resident's body for two of nine random residents (8 and 10) as well as the deceased resident. Findings include: 1. Observation on [DATE] from 12:10 p.m. through 12:25 p.m. in the Bistro dining room revealed: *The funeral home van had backed up directly in front of a large window that could be seen from the Bistro dining room. *At 12:10 p.m. the funeral home had entered the front door with an empty cart. -He passed by the Bistro dining room where approximately twenty residents were waiting for lunch. *At 12:25 p.m. the funeral home passed the dining room again with the body of a deceased resident on the cart. *The window blinds were left open. *The loading of the body in the van was visible to the residents in the dining room. *Also an unidentified visitor was coming in the front door at that time. Observation and overheard conversation on [DATE] from 12:10 p.m. through 12:25 p.m. of resident 8's conversation with his table mates revealed he: *Had said to his table mates, I just hate it when he backs up right there and brings that cart in the front door. *Also conversed about: -When the body was taken out past the dining room and into the van, they had not liked that. -They had not liked the way the window was left open, and that was not right. On [DATE] at 3:00 p.m. during the resident group interview revealed resident's 8 and 10 stated: *They did not think the funeral home should remove a deceased resident's body out of the front door during meal time. -It happened frequently during meal time. *They thought it was very disrespectful to the deceased and for the residents in the dining room. Interview on [DATE] at 7:25 a.m. with the director of nursing (DON) and administrator revealed: *They were unaware the above happening would have bothered any residents. *They knew the deceased resident had been taken out the front door during lunch on [DATE]. *There were other doors available for the funeral home to use. A policy was requested from the DON concerning the removal of a deceased resident's body. She stated they did not have a policy.", "filedate": "2020-09-01"}
{"rowid": 78, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 248, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on observation, record review, interview, and policy review, the provider failed to ensure activities were individualized for 2 of 13 sampled residents (3 and 13). Findings include: 1. Random observations on 1/31/17 from 9:15 a.m. through 11:50 a.m. of resident 3 revealed she had been in her room sitting in the recliner with her eyes closed. Observation on 1/31/17 from 3:00 p.m. through 3:30 p.m. of resident 3 revealed she was slouched in her wheelchair sitting by the nurses station. There had been no one talking with her. Review of resident 3's 11/24/16 Minimum Data Set assessment revealed: *Her vision was moderately impaired. *Her Brief Interview for Mental Status (BIMS) score was a three. -A score of zero through seven meant her thinking ability was severely impaired. *It was very important for her to: -Have music. -Be around animals. -Keep up with the news. -Participate in group activities. -Do her favorite activities (none listed). -Go outside. -Participate in religious activities. Review of resident 3's current undated care plan revealed: *A focus area: I enjoy some in room activities. -Interventions were: --I watch television in my room/open court/activity room daily. --I enjoy news, movies, game shows, and other desired programs. --Staff assist me to read mail I receive. --Staff provide me with 1:1 (one-to-one) visits PRN (as needed). *A focus area: I enjoy some specific planned activities. -Interventions were: --I am provided with salon services as scheduled/desired. --I attend Christian life services as scheduled on Sunday. --I enjoy attending special events/music when scheduled. --I enjoy nailcare as scheduled/desired. --I enjoy participation in crafts as scheduled. --I enjoy socializing with other residents and staff throughout the day. --My family/friends visit for socialization. --Staff assist me with calling my daughter weekly. --Staff invite/escort me to games as scheduled. --Staff need to anticipate (resident name) needs d/t (due to) her poor vision and she may need help with her activity/craft. --Staff provide a monthly activity calendar in my room and assist me to review it as necessary. Review of resident 3's 1/1/17 through 1/31/17 activities participation records revealed she: *Attended church two times. *Had crafts one time. *Had current events two times. *Had hair appointments three times. *There had been no one-to-one activities documented. Interview on 2/1/17 at 10:10 a.m. with the activities director regarding resident 3 revealed she was not aware of how to access her activity records. She stated they only did a one-to-one program with residents receiving hospice services. She agreed resident 3 had a visual impairment and was confused. She stated the resident would sometimes be brought to the group activities, but she did not participate. They had not provided individualized assistance during those group activities. Review of the provider's (MONTH) (YEAR) Providing Meaningful Activities Individual Programming policy revealed individual programming was to ensure all residents who were unable to participate in group programs had consistent, person centered, goal-oriented, and individualized recreation opportunities. 2. Observation at the noon and supper meals on 1/13/17 of resident 13 revealed he sat at a table by himself. Further observations on 1/13/17 from 8:00 a.m. until 5:30 p.m. revealed he had a room by himself, and spent most of his day in his room watching TV or laying on his bed. Review of resident 13's 12/14/16 Activities Interview for Customary and Routines assessment completed by the activity director revealed: *It was very important for him to: -Have books, newspapers, and magazines to read. -List to music he liked. -Keep up with the news. -Do his favorite activities. -Get fresh air when the weather was nice. -To participate in religious services. Review of resident 13's printed 2/1/17 care plan revealed on 4/20/15: *Focus: I show a need for mental stimulation, diversion, relaxation, and enjoy interaction with others as evidenced during interview. -Intervention: I enjoy socializing with other residents and staff during meals and activity events. --Staff invite/escort me to current events as scheduled. --Staff invite/escort me to special activity events as scheduled. *Focus I enjoy some specific activities in open court, activity room and off unit. -Intervention: I enjoy attending Catholic mass/communion as scheduled on Wednesday. -I enjoy attending Christian Life Services as scheduled on Sunday. -I enjoy being involved in poker runs that are planned by the activity department. -Staff invite/escort me to group musicals as scheduled. Interview on 2/1/17 at 9:45 a.m. with the activity director regarding resident 13 revealed: *There was a reason he did not have a roommate or tablemate. -He had chased off every tablemate he had, and they requested to be moved to another table. *He liked staff and visited with them when he got to know them. *He had not come to activities because his behavior was unpredictable. He would come to mass. -He liked church services and his family visits. *He liked music activities but that was only offered one time per month. *He did not like males and became aggressive towards them. *He liked to go to Deadwood whenever that was scheduled, but that occurred mostly in the summer. *They had not gone on poker runs for over two years. *He had not come to current events, but he watched TV and read the paper. *She was unable to provide documentation of any of his activity involvement. *Her staff documented everyday the activities the residents came to. -She was unable to retrieve from the computer the activities he had participated in, because she did not know how. -She could not say for sure how she summarized his activity participation in his quarterly assessment without reviewing any documentation. --She just knew the residents. -She just knew he had not attended activities that were part of his assessed interests because of his behaviors. A later interview on 2/1/17 at 1:00 p.m. with the activity director and review of the (MONTH) (YEAR) activity participation records revealed: *He had attended: -Special events once. -Church services/mass twice. -Current events five times, but that did not clarify if that was his watching TV, reading the newspaper, or coming to the event. -Music once. -Hair cut once. Review of the provider's undated Participation in Activities policy revealed Residents are encouraged to attend and participate in activities of their choosing. Review of the provider's undated Individual Activities policy revealed: It is the policy of this facility that individual activities be provided for those residents whose physical disabilities prohibit movement to other types of activities, and to those residents who do not wish to attend group activities.", "filedate": "2020-09-01"}
{"rowid": 79, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 253, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on observation, interview, and manufacturer's instructions, the provider failed to have four of four different types of lifts on a preventative maintenance checklist. Findings include: 1. Random observations from 1/31/17 through 2/1/17 throughout the facility revealed: *There were four different brands and types of lifts in-use. -Arjo. -Invacare. -Medcare. -EZ lift. Interview on 2/1/17 at 1:00 p.m. with the maintenance supervisor and the administrator revealed they had not had any of the lifts on a preventative maintenance program. The certified nursing assistants would bring the lifts to the maintenance area if they were not working. They were unaware of what lifts needed clips and what lifts did not need them. Review of the manufacturer's instructions for the Arjo lifts revealed inspections should have been done monthly. Review of the manufacturer's instructions for the Invacare lifts revealed inspections should have been done monthly. Review of the manufacturer's instructions for the Medcare lifts revealed inspections should have been done daily and periodically. Review of the manufacturer's instructions for the EZ lifts revealed inspections should have been done every six months.", "filedate": "2020-09-01"}
{"rowid": 80, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on observation, record review, interview, and policy review, the provider failed to update and follow care plans for 2 of 13 sampled residents (3 and 13). Findings include: 1. Observation on 1/31/17 at 9:10 a.m. of resident 3 revealed she had been: *In her room sitting half-way off the seat of her wheelchair. -Scooting around her room with her feet. *Attempting to pick clothes up off the recliner and was leaning forward. Interview on 1/31/17 at 9:50 a.m. with the director of nursing (DON) regarding resident 3 revealed she used to use a walker. She had not used a walker since (MONTH) (YEAR). She currently got around in her wheelchair. Observation on 1/31/17 from 11:50 a.m. through 12:35 p.m. of resident 3 revealed: *She had been served her food at 12:20 p.m. *She was served turkey with gravy, round small white potatoes, a bun, and fruit in a separate bowl. *Her neighbor cut up the turkey for her. Review of resident 3's current undated care plan revealed: *She was supposed to have her meat cut-up. *It stated she ambulated with a four wheeled walker. *Resident often refuses to sit in a chair and wants to sit on her walker, she has been educated on safety with her walker, and staff will continue to encourage her to sit in a chair at the table. Interview on 2/1/17 at 2:30 p.m. with the DON, the administrator, and the nurse consultant regarding resident 3 revealed the care plan had not been updated to reflect she was no longer using the walker. They were not aware the dietary staff had not been cutting up her meat but agreed she would not have been able to do it herself. Review of the provider's (MONTH) (YEAR) care planning policy revealed: *Care planning was constantly in process. *Care plans should be updated between care conferences to reflect current care needs. *Any information updated or discontinued in the resident's care plan will include the date of the changes. 2. Observation on 1/31/17 of resident 13 at the 12:00 noon and supper meals revealed he sat at a table by himself. Further observations revealed he had a room by himself. A confidential complaint on 1/31/17 from another resident revealed resident 13 had been very aggressive toward him. He was concerned that staff had not appropriately addressed his behaviors. Review of resident 13's 8/22/16 nursing progress notes revealed: *Resident became aggressive towards roommate and threatened to hit. Approximately 5 to 10 minutes later resident did hit roommate, (resident's name) over a disagreement with the curtain and TV. Both residents were spoken to by nurse to confirm incident. Nurse then spoke to resident in regards to inappropriate behavior and encouraged resident to call for nurse in future so a future episode like this may be avoided. *10/10/16: Situation between resident number (facility number) and (resident room number) where words were exchanged and a bubble cup was thrown and resident (facility number) was ultimately hit in forehead with bubble cup. Background: Resident has hx (history) of aggression towards one another as well as other residents and staff. Interview on 2/1/17 at 9:15 a.m. of certified nursing assistant (CNA) A regarding resident 13 revealed: *For the most part he was very pleasant. *He had not required any assistance with care, so he did not have a lot to do with him. *He had problems in the past with not getting along with other residents at the table, so that was why he sat alone at meals. Interview on 2/1/17 at 9:30 a.m. with bath aide B regarding resident 13 revealed: *She had no problems with giving him a bath; he was cooperative. *He could not have a roommate, because he had hit them in the past. Interview on 2/1/17 at 10:00 a.m. with the director of nursing regarding resident 13 revealed: *They had problems with him in the past that had contributed to why he did not have a roommate. *He did not like females. *His behaviors were sneaky; he said things under his breath that were mean or aggressive towards other residents. -He would try not to do it if staff could hear him. Review of resident 13's printed 2/1/17 care plan revealed on 4/20/15 they had implemented: *Focus: I show a need for mental stimulation, diversion, relaxation, and enjoy interaction with others as evidenced during interview. -Intervention: I enjoy socializing with other residents and staff during meals and activity events. --Staff invite/escort me to current events as scheduled. --Staff invite/escort me to special activity events as scheduled. *Focus: I enjoy some specific activities in open court, activity room and off unit. -Intervention: I enjoy attending Catholic Mass/Communion as scheduled on Wednesday. -I enjoy attending Christian Life Services as scheduled on Sunday. -I enjoy being involved in poker runs that are planned by the activity department. -Staff invite/escort me to group musicals as scheduled. *Focus: I have a hx (history) of resisting cares and do not like to have help. - Intervention: I prefer male caregivers over female caregivers if able, I accept help from males better than females. *Focus: Behavior/Coping: I have behavior issues that can interfere with my day to day activities that include: I become aggressive with females, more than males, due to a poor relationship with my mother as indicated by my family. -Interventions: (mental health facility name) provide me with consultation as needed. I have a history of being verbally abusive towards other residents. Please monitor me when I am out of my room. The above care plan did not address: *How to prevent the behaviors from happening. *The potential for physical aggression. *Updates of activities the resident was attending, and what was no longer available such as poker runs. *How they met the resident's activity needs since he was not able to attend activities because of concern over his behaviors. *The varying information regarding his preference males or females. *The benefit of his eating at a table alone, and having a private room to manage behaviors. Interview on 2/1/17 at 1:00 p.m. with the activity director regarding resident 13 revealed: *There was a reason he did not have a roommate or tablemate. -He had chased off every tablemate ever he had. --They had requested to be moved to another table. *He had not come to activities because his behavior was unpredictable. He would come to Mass. -He liked church services and his family visits. *He did not like males. *He liked to go to Deadwood whenever that was scheduled. *They had not gone on poker runs for over two years. *She confirmed the care plan was not current. Review of the provider's undated activity care plan policy revealed: *1. An individualized activity care plan is maintained for each resident. *2. This plan contains activities that the resident enjoys, or may enjoy, and has been approved by the resident's attending physician. *3. Individualized activity plans are incorporated into the resident's total care plan. *4. Activity plans are reviewed and/or revised as necessary, but at least quarterly.", "filedate": "2020-09-01"}
{"rowid": 81, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 283, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure a summary for one of one sampled discharged resident's (15) stay was completed. Findings include: 1. Review of resident 15's medical record revealed he had been admitted on [DATE] and discharged on [DATE]. He had received therapies to recover from hematuria and a urinary tract infection. No summary of his stay was found within that record. Interview on 2/1/17 at 10:30 a.m. with the director of nursing confirmed no discharge summary had been completed on resident 15. She stated one should have been completed since the discharge was anticipated. Review of the provider's (MONTH) (YEAR) Discharge Plan and Summary policy revealed: *The interdisciplinary team would complete the discharge summary on all residents who were discharged . *That summary should have included a recapitulation of the resident's stay including: -Diagnosis. -Course of disorder/treatment or therapy. -Pertinent lab, radiology, and consult reports. -A final summary of the resident's stauts to include items in the comprehensive assessment at the time of discharge. -A post-discharge plan of care.", "filedate": "2020-09-01"}
{"rowid": 82, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 312, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on observation, record review, interview, and policy review, the provider failed to ensure assistance with eating was given to one of one sampled resident (3) who had a visual impairment and impaired thinking ability. Findings include: 1. Review of resident 3's 11/24/16 Minimum Data Set assessment revealed: *Her vision was moderately impaired. *Her Brief Interview for Mental Status (BIMS) score was a three. -A score of zero through seven meant her thinking ability was severely impaired. *She was independent with eating, and only needed set-up help. Observation on 1/31/17 from 11:50 a.m. through 12:35 p.m. of resident 3 in the dining room revealed: *She had been served her food at 12:20 p.m. *She was served turkey with gravy, round small white potatoes, a bun, and fruit in a separate bowl. *She was unable to find her silverware. *She used her fingers to pick up the potatoes. *Her neighbor at the table had told her where her silverware were. *She stabbed the whole bun with her fork. *Her neighbor told her not to do that and instructed her to pull the bun apart. *Her neighbor cut up the turkey for her. *At 12:30 p.m. she asked this surveyor what was on her plate and stated she could not see what was on it. *The turkey was pointed out to her, and she still could not see it or pick it up with a fork. *She asked this surveyor where the potatoes were and continued to poke around on her plate until she was shown. Observation on 1/31/17 from 5:25 p.m. through 6:10 p.m. of resident 3 in the dining room revealed: *At 5:45 p.m. she had been served a sandwich, beets in a cup, and soup by the licensed social worker (LSW). *Her neighbor had told her to wake up. *She told the LSW she could not see the food. *The LSW dumped the beets onto her plate with the sandwich. *She used her fork for her soup. *She asked what the sandwich was, and staff told her she could pick it up with her hands. *She then attempted to pick up the bowl of soup. -Staff stopped her before it had spilled. *She asked again what her sandwich was. *She was poking around at the beets and was unable to get them on her fork. -She lifted the fork to her mouth three times with no beets on the fork. *At 5:50 p.m. the LSW brought a chair over and assisted her with eating. *At 5:55 p.m. the activities director took the LSW's place at the table to assist the resident. *The resident was stabbing the sandwich with a fork and the staff told her she could pick it up with her hands. Interview on 1/31/17 at 6:00 p.m. with the activities director regarding resident 3 revealed she was unaware if she was supposed to receive help with eating. The LSW had asked her to sit there. She stated Sometimes she eats and sometimes she doesn't. She stated she normally only needed cueing to eat. Interview on 1/31/17 at 6:10 p.m. with the dietary manager regarding resident 3 revealed they had attempted to move her to the assisted room, but she had refused. She agreed she was confused and needed assistance. Staff were to tell her where the food was located based on the dial of a clock. She agreed someone who was confused might not be able to remember that information. She was unable to provide what other interventions had been attempted for her. Interview on 2/1/17 at 2:30 p.m. with the director of nursing, the administrator, and the nurse consultant regarding resident 3 revealed: *She had a visual impairment. *She was confused and had impaired thinking ability. *She had been declining and was offered to be moved into the assisted dining room, but she had refused. *Agreed it was her right to refuse to move and to stay at her current table. Review of the provider's undated Dining Experience policy revealed it had not addressed residents who needed assistance with eating.", "filedate": "2020-09-01"}
{"rowid": 83, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on observation, record review, interview, and policy review, the provider failed to complete fall risk assessments, implement interventions, and complete thorough fall investigations for one of one sampled resident (3) who had multiple falls. Findings include: 1. Observation on 1/31/17 at 9:10 a.m. of resident 3 revealed she had been: *In her room sitting half-way off the seat of her wheelchair. *Confused when talking to the medication aide. *Scooting around in her room in her wheelchair with her feet. *Attempting to pick clothes up off the recliner and was leaning forward. Review of resident 3's medical record revealed she had fallen on 1/28/16, 1/29/16, 2/1/16, 3/8/16, 6/3/16, 7/4/16, 10/5/16, 10/7/16, 10/8/16, 10/18/16, 11/2/16, 11/26/16, 12/18/16, and 1/17/17. Review of resident 3's 8/24/16 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was a three. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 11/24/16 MDS assessment revealed her BIMS score was a one. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 5/16/16 Fall Risk assessment revealed: *She had a score of fourteen. -A score of ten or above indicated a risk for falling. *There had not been an (MONTH) (YEAR) or (MONTH) (YEAR) Fall Risk assessment completed. Review of resident 3's 10/5/16 Fall Scene Investigation report revealed: *She had lost her balance while reaching for a piece of paper on the floor. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time?) section had not been completed. *There had been no change to the current care plan. Review of resident 3's 10/7/16 Fall Scene Investigation report revealed: *She had lost her balance while reaching for a piece of paper on the floor. *The medications given in last 8 hours section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *The root cause of the fall section had not been completed. *There had been no change to the current care plan. *Refer to therapy to screen was written under conclusion. Review of resident 3's 10/8/16 Fall Scene Investigation report revealed: *She had been walking into room and legs appeared to go out. *The last time toileted section had not been completed. *The medications given in last 8 hours section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *The root cause of the fall section had not been completed. *There had been no change to the current care plan. *An initial intervention had been Have a separate staff member in day room or activity room keeping a close eye on our high risk individuals. *Refer to therapy to screen was written under conclusion. Review of resident 3's 10/18/16 Fall Scene Investigation report revealed: *She had been found sitting on the floor in her room. *The medications given in last 8 hours section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *The root cause of the fall section had not been completed. *There had been no change to the current care plan. *There had been no initial interventions documented. *Continue to encourage her to call for help was written under conclusion. Review of resident 3's 11/2/16 Fall Scene Investigation report revealed: *She had been found sitting on the floor in the bathroom. *The last time toileted section had not been completed. *The medications given in last 8 hours section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *The root cause of the fall section had not been completed. *There had been no change to the current care plan. *There had been no initial interventions documented. *Staff to check on often was written under conclusion. Review of resident 3's 11/26/16 Fall Scene Investigation report revealed: *She had slipped out of the wheelchair. *The last time toileted section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *The root cause of the fall section had not been completed. *There had been no change to the current care plan. *There had been no initial interventions documented. Review of resident 3's 12/18/16 Fall Scene Investigation report revealed: *She had been found sitting on the floor in her room. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time) section had not been completed. *There had been no change to the current care plan. *The initial intervention was Monitor resident closely, anticipate needs. Resident should not be left in room alone when awake and alert. Take to open court in day room until ready to sleep. *Under conclusion Activities notified to try to include her in activities. Review of resident 3's 1/17/17 Fall Scene Investigation report revealed: *She had slid out of her recliner. *There had been no change to the current care plan. *Under initial interventions Instructed resident on use of controls and to use call light if assistance is needed. Review of resident 3's current undated care plan revealed: *She had a focus area for falls. *The interventions had been: -Ensure my call light and/or pendant is within reach. Keep my room and hallway free from clutter initiated on 10/5/14 and revised on 7/25/16. -I am using a w/c (wheelchair) so I can propel myself around the facility independently initiated on 11/16/16. -I am working with restorative therapy to help improve my strength and abilities initiated on 10/5/14 and revised on 10/16/15. -I will need staff to check on me frequently related to my confused state to see if I have any needs. I do not always remember to use my call light. I have a pendant alarm, but do not always remember to carry it with me. I do often take my pendant off so monitor for this and put it back on as needed. I have poor safely awareness and am not able to anticipate hazardous situations initiated 10/5/14 and revised on 12/19/16. -Keep my lamp on at night initiated 11/9/15. -Self locking brakes to my w/c. I often transfer myself despite being educated to not transfer self and to call for assist. Check on me frequently. I also often shut my door when I am in my room, monitor for this and open it up. Also encourage me to stay in open court, activity room or day room so my whereabouts can be monitored more closely initiated on 12/19/16. Review of resident 3's discontinued care plan revealed the discontinued interventions for the fall focus area were: *Cup holder placed on walker to prevent tipping of cup. *Will place cup holder on walker. *Keep my walker within reach at all times. *There had been no other interventions listed on that care plan under the focus area for falls. Interview on 2/1/17 at 8:50 a.m. with the restorative aide revealed resident 3 was scheduled for restorative therapy three times per week. Her scheduled days were Monday, Tuesday, and Wednesday. She mostly attended the group activity that worked on the upper extremities. She had the Nu-Step listed as PRN (as needed). She would offer the Nu-Step to the resident if she refused to attend the group restorative activity. The resident seemed to like the Nu-Step. She was the only restorative aide for forty-five residents. Interview on 2/1/17 at 2:30 p.m. with the director of nursing, the administrator, and the nurse consultant regarding resident 3 and the above fall history revealed: *They had no documentation she had seen therapy for a screening as part of the intervention from the 10/7/16 and 10/8/16 falls. *There was no documentation they had been monitoring the resident more closely. *They agreed a resident with a BIMS of one might not remember to use the call light. *They had disabled the control on the recliner in her room after the incident on 1/17/17. -They agreed that could have been done before as an environmental intervention. *The fall scene investigation reports had not been complete. *They had not completed the fall risk assessments quarterly as they should have been done. Review of the provider's (MONTH) (YEAR) Fall Prevention policy revealed: *A fall risk assessment should have been completed upon admission, quarterly, prior to the annual MDS, and with a change in condition. *Fall precautions were to be reviewed and implemented after a fall occurred and as needed. *The care plan was to be updated with any new and decided upon interventions. -That was to continue for three weeks post-fall or until the resident had not had further falls for thirty days.", "filedate": "2020-09-01"}
{"rowid": 84, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2017-02-01", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "X0TZ11", "inspection_text": "Based on interview and policy review, the provider failed to ensure lift slings and lifts were appropriately cleaned between residents on four of four resident wings (100, 200, 300, and 400). Findings include: 1. Interview on 1/31/17 at 11:35 a.m. with certified nursing assistant (CNA) B revealed: *Lift slings were usually stored on the lift and were used for multiple residents. *The lifts should have been wiped off between residents, but that was not always done. *Slings were sent to laundry when visibly soiled. Interview on 2/1/17 at 7:20 a.m. with CNA C revealed: *Lift slings were used for multiple residents. *Slings were sent to laundry only when visibly soiled. *Lifts were not always wiped off between residents use. Interview on 2/1/17 at 7:25 a.m. with the administrator and the director of nursing revealed: *When slings were visibly dirty they would send them to laundry. *Management had talked about getting everyone their own sling. *Lifts were to have been wiped down every night. Review of the (MONTH) (YEAR) Safe Lifting and Moving of a Resident policy revealed residents would have been provided with single-resident use disposable slings.", "filedate": "2020-09-01"}
{"rowid": 85, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 580, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure notification to the physician had occurred with a change in condition for one of two sampled residents (47) who had shortness of breath. Findings include: 1. Interview on 2/27/18 at 2:30 p.m. with resident 47 and her power of attorney (POA) during the resident council meeting revealed: *She had felt short of breath last night (2/26/18) and thought she had an order to have her inhaler more then one time per day. *She asked the nurse when she had gotten her inhaler last and told her she needed it again, but the nurse would not give it to her. *The nurse had told her she did not have an order to have it more then one time per day. *It had made her feel bad that she could not have her inhaler. *The POA stated he had spoken with a staff member today, and they stated they were not able to find the order she could have the inhaler more then one time per day. Review of resident 47's 2/6/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status score was fourteen indicating she had no cognitive impairment. *She had been independent with transfers, walking, and personal hygiene. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Heart failure. -Hypertension. -[MEDICAL CONDITION]. -Arthritis. -[MEDICAL CONDITION]. -Depression. -Asthma. *Section J revealed her health conditions included shortness of breath with exertion. Phone interview on 3/01/18 at 10:30 a.m. with resident 47's POA revealed: *He thought she had an order prior to entering the facility to get the inhaler more then one time per day. *But when she had been admitted to the facility they had switched her physician, and he was not aware of what changes they had made to her medications. *The staff member he had spoken to on 2/27/18 had been the director of nursing (DON). -She could not find the order for an inhaler for more then one time per day. -She had scheduled the resident to meet with the physician on 3/1/18. *He had not been able to connect with the physician to discuss the resident's medical issues. Interview on 3/01/18 at 10:51 a.m. with resident 47 revealed: *She could not remember the name of the nurse working the night she had felt short of breath. *The nurse was not a new nurse to the facility. *She stated the nurse could not find the inhaler order and had not done anything to assist her. Review of resident 47's medical record revealed: *She had been admitted on [DATE]. *There had been no: -Nursing progress notes regarding the situation described above. -Documentation of the assessment completed by the nurse regarding the resident's shortness of breath. -Documentation the physician had been notified regarding the resident's change in condition. Review of the nursing schedule revealed registered nurse (RN) K had been the nurse working 6:00 p.m. to 6:30 p.m. on 2/26/18. A phone interview had been attempted on 3/01/18 at 11:16 a.m. with RN K, but she had not answered. Interview on 3/01/18 at 2:37 p.m. with the DON regarding resident 47 revealed: *She had spoken to the POA on 2/27/18 regarding the resident's inhaler order. *She had not documented her discussion with the PO[NAME] *She had not been aware of the incident with the resident having shortness of breath on 2/26/17. *She had not been aware there was no documentation regarding the incident. *She would have expected the nurse to contact the physician if the resident had been experiencing shortness of breath. Review of the provider's (MONTH) (YEAR) Resident, Physician, and Resident Representative(s) Notification policy revealed: *The facility will immediately inform the resident; consult with the Physician/PA/NP; and inform the Resident Representative(s) when there is a change in condition such as but not limited to: -A significant change in the resident's physical, mental, or psychosocial status; deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. -A need to alter treatment significantly, such as discontinuing an existing treatment or commence a new treatment.", "filedate": "2020-09-01"}
{"rowid": 86, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 600, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review, the provider failed to ensure one of one sampled resident (43) who was dependent upon the staff for all activities of daily living (ADL) was not left on a toileting device for an extended period of time resulting in bruising to the skin. Findings include: 1. Record review for resident 43 revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status score was eleven indicating she had moderate impairment. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. *She was dependent upon the staff for all her ADL. Record review of a 2/18/18 incident regarding resident 43. revealed: *CNAs W and V had assisted her onto a bedpan on 2/18/18 at 5:08 p.m. *CNA W did not check back on her. *She was left on the bedpan for over an hour. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. *CNA R had answered her call light and discovered she was on the bedpan. -Resident stated her hip hurt. -Cleaned her up and went to get the nurse. *RN K assessed her and found a 1.5 inch by 6 inch bruise in the shape of the bedpan on her left hip/buttock area. *Resident had been interviewed by RN K and the administrator by phone. -She had not remembered being on the bedpan. -She had not used the call light for assistance off the bedpan. -She had put her call light on when she noticed her hip hurt. *Both CNAs were suspended pending the investigation. -CNA V had returned to work the next day, 2/19/18. -CNA V was educated on the new bedpan use. -CNA W resigned without notice. *Findings were substantiated. *QAPI with immediate education began 2/18/18. Interview on 2/27/18 at 1:00 p.m. with registered nurse (RN) I regarding resident 43 care revealed: *She needed total assistance of two staff with a Hoyer lift for transfers. *She used a bed pan for her bladder and bowel needs. -She did not have use of her extremities. -She had the potential for skin break down. *She had the potential for skin break down. *She was able to move her head up and down. *She used a soft touch pendant for her call light. Interview and observation on 02/27/18 at 4:00 p.m. with resident 43 regarding the call lights and the 2/18/18 incident revealed she: *Acknowledged the 2/18/18 incident had occurred. -Had been placed on the bedpan. -Had not been taken off the bedpan for over an hour. -That had made her upset and uncomfortable. -Put on her call light when her hip started to hurt. -Stated CNA R had come to help her off the bedpan. *Needed total assistance of two staff with a Hoyer lift for transfers. *Used a bedpan for her bladder and bowel needs. *Was now checked on frequently when put on the bedpan. *Had no use of her extremities. *Was able to move her head up and down. *Used a soft touch pendant for her call light. *She would depress the call light with her chin. *Staff attached the call light to the bed sheet or her clothing. -That prevented the call light from falling or slipping. *She stated Since the bedpan incident they check on me frequently. -She stated her call light was answered quickly since the 2/18/18 incident. Interview on 2/28/18 at 2:30 p.m. with CNA T regarding resident 43's care and the call light revealed: *She stated Since the incident where the resident was left on the bed pan and forgotten: -She was watched closely throughout the day. *Used a bedpan for her bladder and bowel needs. *She was checked every five minutes while on the bedpan. *The staff had been educated to get a nurse: -If she requested to be on the bedpan longer than twenty minutes. -Nurse would educate her on the potential for skin breakdown. *The digital board at the end of the hallway would light up when a call light was pressed. -It would display the resident's room number. *The resident's room number would be displayed on the computer screen at the nurses station. *To her knowledge that was the only way to know if the resident had put on their call light. *There was no alarm system alerting them of a call light being on. *Staff had walkie-talkies to use if they needed assistance from other staff. Interview on 2/28/18 at 2:40 p.m. with CNA R regarding the care of resident 43 revealed she: *Had a [DIAGNOSES REDACTED]. *Needed total assistance of two staff with a Hoyer lift for transfers. *Was checked on every two hours. *Was a vulnerable resident. *She had no use of her extremities. *Used a bedpan for her bladder and bowel needs. *Staff had been educated to check residents every five minutes when on the bed pan. *Acknowledged an incident where the resident had been placed on the bedpan and forgotten. -She was not sure how long the resident had been on the bedpan *An incident report had been filled out. Interview on 2/28/18 at 3:55 with the director of social services regarding resident 43 revealed: *She was a vulnerable resident. *Facility had a new bedpan usage policy in place. *Staff had been educated on the new bedpan usage policy. Interview on 2/28/18 at 10:00 with the director of nursing regarding the 2/18/18 incident with resident 43 revealed: *She acknowledged the incident had taken place. *It was reported to the local law enforcement. *It was reported to the state. *She provided copies of the: -Incident report filed with the state. -Internal investigation form. *They had procedures in place to prevent that from happening in the future such as: -Quality assurance performance improvement (QAPI) plan for bedpan usage. -Check resident every five minutes while on the bedpan. -After twenty minutes get the nurse. -Nurse to educate resident on the risk. -Reposition resident and check every five minutes. -Staff were educated on the new procedures. *Her care plan had been updated after the incident to reflect her current bladder and bowel needs. Record review of the 2/18/18 QAPI meeting minutes interventions revealed: *Immediate education was given to all staff to check on all residents who are put on a bed pan every 5 mins (minutes) to see if they are ready to be taken off the bed pan. If they are not taken off after 20 mins (minutes), the nurse needs to explain the risks to the resident and if they still request to stay on the bed pan, the resident should be repositioned on the bed pan and checked again every 5 mins (minutes), and nurse assessment every 20 minutes. *Audits x (times) 4 weeks and reviewed for continuation at QAPI. Record review of the 2/18/18 incident regarding resident 43. revealed: *CNAs W and V had assisted her onto a bedpan on 2/18/18 at 5:08 p.m. *CNA W did not check back on her. *She was left on the bedpan for over an hour. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. *CNA R had answered her call light and discovered she was on the bedpan. -Resident stated hip hurt. -Cleaned her up and went to get the nurse. *RN K assessed her and found a 1.5 inch by 6 inch bruise in the shape of the bedpan on her left hip/buttock area. *Resident had been interviewed by RN K and the administrator by phone. -She had not remembered being on the bedpan. -She had not used the call light for assistance off the bedpan. -She had put her call light on when she noticed her hip hurt. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. *Both CNAs were suspended pending the investigation. -CNA V had returned to work the next day, 2/19/18. -CNA V was educated on the new bedpan use. -CNA W resigned without notice. *Findings were substantiated. *QAPI with immediate education began 2/18/18. Review of the following device activity report (call light report) for resident 43 revealed: *On 2/16/18 at 8:39 p.m. call light was on for sixty-four minutes and fifty-five seconds before being turned off. *On 2/18/18 at 10:35 a.m. call light was on for thirty-two minutes and fifty-seven seconds before being turned off. *On 2/18/18 at 6:48 p.m. call light was on for twenty-one minutes and twenty-six seconds before being turned off. Review of the revised 2/21/18 care plan for resident 43 revealed: *Her current bladder and bowel needs had been updated on 2/19/18. -I have a history of pushing my call light after I am done using the bed pan, but am not frequently doing so anymore and would like staff to check frequently on me while I am on the bed pan. *The new bedpan usage policy for checking resident every five minutes while on the bedpan, was not on her care plan. Review of the revised (MONTH) 2014 Bedpan Urinal, Offering or Removal policy and procedure revealed: Do not allow the resident to sit on a bedpan for extended periods. (Note: This is not only uncomfortable to the resident, it also causes skin breakdown.) Review of the revised (MONTH) (YEAR) Abuse Prevention plan-South Dakota revealed: *In accordance with the Vulnerable Adult Law of the State and the Centers for Medicare and Medicaid, (CMS), it is our policy that all residents residing in the facility will be protected from abuse, neglect, and that interventions are implemented to provide the vulnerable adult with a safe living environment. *All residents have the right to be free of abuse and neglect. *A vulnerable adult means any resident receiving services from this facility who may be unable to report maltreatment without assistance due to physical or mental impairment. *Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *(CMS Definition) Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.", "filedate": "2020-09-01"}
{"rowid": 87, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 610, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to thoroughly investigate twenty-four falls for one of five sampled residents (41). Findings include: 1a. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had twenty-four falls since her admission date of [DATE]. -Two of those falls resulted in major injury. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. Review of resident 41's 12/19/17 fall scene investigation reports revealed: *She had been found on the floor of the bathroom at 9:00 p.m. -She crawled out of bed and got to the bathroom. -She urinated on bathroom floor and had a lg (large) round BM (bowel movement) which she was holding in her left hand. -She moved all extremities and tried to crawl back to her bed during assessment. -What appeared to be the root cause of the fall had been Needing to toilet. --At 4:00 a.m. Res (resident) has been caught 6x's (times) trying to crawl out of bed. She needed and voided in toilet each time. -They had added one hour checks to her care plan. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. b. Review of resident 41's 12/29/17 fall scene investigation reports revealed: *She was found on the floor at 10:30 a.m. in the resident's room by the bathroom door. -She had been alone and unattended. -Resident stated she was trying to get to the bathroom. -Last time she had been toileted was at 8:30 a.m. --She had been dry but Had a BM right away. -The root cause had been Resident has unsteady gait. -Initial interventions to prevent future falls had been Educated staff to cue resident to toilet every 2 hours and PRN (as needed). -Summary of falls team meeting had been Resident attempted to toilet self after breakfast. -There had been no conclusion or additional care plan updates documented. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. c. Review of resident 41's 12/30/17 fall scene investigation reports revealed: *She had been found on the floor in the resident's room in the doorway at 8:50 p.m. -She had been alone and unattended. -Staff were unsure if she had been crawling, but her bed had been in low position. -The last time toileted had been marked unsure. -Conclusion had been Cont with low bed/mat. She continues to crawl out of bed. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. d. Review of resident 41's 1/3/18 fall scene investigation reports revealed: *She had been found sitting on the mat next to her bed at 2:20 a.m. -Last time toileted had been at 12:10 a.m., and she had been dry. -Root cause had been been Cont to crawl out of bed. Toileting. -Initial interventions to prevent future falls had been Cont with low bed/mat. Cont with toileting upon rising, before and after meals, before bed and PRN. -Conclusion had been Cont with frequent toileting, checks and low bed/mat. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. e. Review of resident 41's 1/3/18 fall scene investigation reports revealed: *She had been found on the floor at 6:30 a.m. by the bathroom door. -She had been alone and unattended. -When the resident was asked what she was doing just before the fall she Kept requesting to go to the BR (bathroom). -The last time toileted had not been completed. -Root cause had been Resident got up per self to go to the BR - too unsteady to stand per self. -Conclusion had been change care plan to toilet every two hours. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. f. Review of resident 41's 1/10/18 fall scene investigation reports revealed: *The resident had been found on the floor in her room by the recliner at 1:45 p.m. -She had been alone and unattended. -When asked what she was doing prior to the fall she Just kept say(ing) 'I have to go to the BR.' -She had last been toileted at 12:30 p.m. --She had been wet and had a BM. -She had been at the hospital prior to this fall, so no medications had been given to her. -Root cause had been Resident attempted to get up per self from recliner chair - had to go to the BR. -Initial interventions to prevent future falls had been Initiate hourly checks. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. g. Review of resident 41's 1/14/18 South Dakota Department of Health report revealed: *She had been found on the floor in front of the recliner by three certified nursing assistants (CNA). *Two of the CNAs had used a gait belt to lift her off the floor prior to notifying the nurse. *She had been sent to the emergency room and was found to have a left [MEDICAL CONDITION]. *There had been no fall scene investigation completed. *There had been no documentation regarding the following investigation areas: -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last assisted her. -If there had been any medication changes. h. Review of resident 41's 2/22/18 fall scene investigation reports revealed: *She fell forward out of her wheelchair (w/c) and hit her head on the floor at 11:20 a.m. -She had been alone and unattended. -She had last been toileted at 9:00 a.m. and had been wet. -Root cause had been Resident leaned forward too far in w/c and fell out. -Initial intervention to prevent future falls had been Resident in w/c only for transportation. -Conclusion had been Recliner or bed between meals. Leg extenders added to w/c. LCD (last completion date) was yest (yesterday) for therapy. Will set up restorative plan. -According to the 2/22/18 attached incident note the Resident was incontinent of urine through her pants. -Per investigation staff were educated to not leave the resident alone in her wheelchair. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -What level of assistance she required. -If the care plan had been followed. -Why she had not been assisted to the bathroom since 9:00 a.m. -Who had last assisted her. -If there had been any medication changes. i. Review of resident 41's interdisciplinary notes from 12/19/17 through 2/27/18 revealed: *She had also fallen on the following dates: -1/2/18. -1/3/18 a third time. -1/4/18. -1/5/18 two times. -1/6/17. -1/27/18. -1/28/18. -2/1/18. -2/2/18 two times. -2/5/18. -2/6/18. -2/7/18. *There had been no fall scene investigation reports or other documentation the above falls had been investigated. j. Interview on 3/01/18 at 2:03 p.m. with the director of nursing revealed she agreed the above falls had not been thoroughly investigated. Review of the provider's (MONTH) (YEAR) Abuse Prevention Plan policy revealed: *Facility will investigate all incidences such as falls, bruises, medication errors, resident complaints, etc. *Facility will identify the staff member(s) responsible for: -The initial report. -Initiating the investigation. -Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. -Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; -Providing complete and thorough documentation of the investigation. -Reporting the results to the proper authority within the 5-day state requirement.", "filedate": "2020-09-01"}
{"rowid": 88, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure the care plan reflected physician's orders for one of one sampled resident (40) who used oxygen and a bilevel positive airway pressure ([MEDICAL CONDITION]) device. Findings include: 1. Review of resident 40's medical record revealed: *Her Brief Interview for Mental Status score was fifteen indicating no cognitive impairment. *She had an above the knee amputation of the left leg. *Her [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus. -Sleep apnea. -Heart failure. -Major [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Gastro-[MEDICAL CONDITION] reflux. -Abnormal posture. -Muscle weakness. *Physician's orders on 4/27/17 for oxygen (02) and [MEDICAL CONDITION]. -Oxygen at 4 liters per minute (lpm) continuous when [MEDICAL CONDITION] not in use. -Oxygen at 10 lpm via [MEDICAL CONDITION] at night and during naps. -[MEDICAL CONDITION] at 16/8 with a backup rate of 12. *Physician's order on 2/2/18 for oxygen. -Oxygen at 2 lpm continuous. -Continue [MEDICAL CONDITION] when sleeping. Observation on 2/27/18 at 3:00 p.m. with resident 40 revealed she had: *Been sitting up in her lift chair taking a nap. *Been wearing oxygen at 2 lpm. *A [MEDICAL CONDITION] machine on her bedside table. Interview on 2/27/18 at 3:00 p.m. with certified nursing assistant (CNA) R regarding resident 40 revealed she used: *Oxygen at 2 lpm during the day. *[MEDICAL CONDITION] at night. Interview on 2/27/18 at 3:15 p.m. with CNA S regarding resident 40 revealed: *She stated I have never seen her wear her [MEDICAL CONDITION] when she takes a nap during the day. *She used oxygen at 2 lpm during the day. Interview and observation on 2/27/18 at 3:30 p.m. with resident 40 revealed: *She had been sitting up in her lift chair and using her oxygen per a nasal cannula. *Oxygen concentrator had been set at 2 lpm. *She stated I only use my oxygen at 2 lpm during the day and 6 lpm with my [MEDICAL CONDITION]. -I have lost weight and my breathing is getting much better. -I only use my [MEDICAL CONDITION] at night. *She no longer took naps in her bed, as she was getting stronger. *She used a stand aid for transfers. *She took naps in her lift chair. Review of resident 40's (MONTH) (YEAR) and (MONTH) (YEAR) treatment administration records (TAR) revealed: *02 at 10 lpm via [MEDICAL CONDITION] at night and during naps. -Start date 4/27/17. *02 at 4 lpm per nasal cannula continuous when [MEDICAL CONDITION] not in use. -Start date 4/27/17. *Documentation of oxygen and [MEDICAL CONDITION] checks from 6 a.m. to 2 a.m., 2 a.m. to 1 p.m., and 10 p.m. Review of resident 40's 2/21/18 revised care plan revealed I USE OXYGEN AT 10 lpm AT N[NAME] (night) with a Bi-Pap. 02 4 lpm DURING THE DAY. Interview on 2/28/18 at 2:55 p.m. with registered nurse (RN) I regarding resident 40 revealed she: *Used [MEDICAL CONDITION] at night with oxygen at 6 lpm bled-in. *Used oxygen at 2 lpm continuous during the day. *Took naps during the day. -Had not used her [MEDICAL CONDITION] for naps. Interview on 3/1/18 at 12:27 p.m. with the director of nursing regarding resident 40 revealed: *Her oxygen order had been changed on 2/2/18. -Oxygen at 2 lpm continuous. -Continue [MEDICAL CONDITION] when sleeping. *The new order had not been changed on the TAR or care plan. -She agreed that should have been changed to reflect the resident's current oxygen orders. *She had been unable to provide an order for [REDACTED]. -Unsure when or why that had been changed. *She planned on calling the [MEDICAL CONDITION] physician for clarification of the following: -Oxygen liter flow for daytime and nighttime. -Oxygen usage for daytime and nighttime. -[MEDICAL CONDITION] usage with or without naps. Review of the provider's revised (MONTH) (YEAR) Physician Order Procedure policy revealed: *To correctly and safely receive and transcribe physician's orders so correct order is followed/administered. *A notation needs to be made in the resident's medical record as to the reason for the new order and a brief summary of what it was. *All transcription of orders should be signed off by a nurse and double checked by a second nurse to assure that all steps have been carried out to avoid errors. The second nurse will run the Administration Record Report for the MAR/Tar to view for accuracy of the transcription. Review of the provider's revised (MONTH) 2014 Physician Services policy revealed: Physician orders and progress notes shall be maintained in accordance with current regulations and facility policy. Review of the provider's revised (MONTH) (YEAR) Care Planning policy revealed: *The physician's orders were referenced in the resident's care plan. *The DON was responsible for updating the care plan.", "filedate": "2020-09-01"}
{"rowid": 89, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, job description review, and policy review, the provider failed to ensure: *Medications were initialed after being administered by one of one registered nurse (RN) (I) who administered medication to resident 61. *Unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to calculate medication doses for two of two sampled residents (14 and 27) who required dosage calculation. *physician's orders [REDACTED]. -One of one sampled resident (10) with a new physician's orders [REDACTED]. -One of one sampled resident (40) who used oxygen and a bilevel positive airway pressure ([MEDICAL CONDITION]) device had been followed. Findings include: 1. Observation on 2/28/18 at 7:50 a.m. of RN I while she prepared medications for resident 61 revealed she signed the resident's medication as having been given as soon as she had finished preparing it. Interview with RN I at that time revealed she had done that because she was only going to administer medication to resident 61. She stated she did not want to have to come back to the medication cart to sign the medication administration record. 2a. Observation and interview on 2/27/18 at 9:00 a.m. of UAP A while she administered medication to resident 27 revealed: *An order on the resident's (MONTH) (YEAR) medication administration record (MAR) stated ranitadine 150 milligrams (mg) (for stomach) in the morning. There ha *There had not been verification on the MAR that had indicated the correct doage was two tablet of ranitadine. *She gave the resident two 75 mg tablets of ranitadine and stated:-She gave two tablets of ranitadine 75 mg to the resident, because there had not been any 150 mg tablets. -There used to be 150 mg tablets. -Now the tablets were 75 mg. -She just knew two 75 mg tablets would equal 150 mg of medication for the resident. -She had not asked a licensed nurse for verification of the correct dose of medication when the tablets had changed from 150 mg to 75 mg. b. Observation and interview on 2/28/18 at 9:00 a.m. of UAP A while she administered medication to resident 14 revealed: *An order on the resident's (MONTH) (YEAR) MAR [MEDICATION NAME] 1000 mg, give two tablets in the a.m. *UAP A gave the resident two 500 mg tablets of [MEDICATION NAME]. *UAP A stated: -She just knew two 500 mg tablets would equal 1000 mg of medication for the resident. -She had not asked a licensed nurse for verification of the correct dose of medication. 3a. Review of resident 25's physician's orders [REDACTED]. Observation on 2/28/18 at 2:30 p.m. of resident 25 while he was laying in bed on his left side revealed: *He had on soft foam covered ankle boots. *His right heel laid directly on the inside of the boot approximately half way up from the heel area. *His right heel had not been exposed in the opened area of the boot meant for off loading. *That ankle boot laid directly on the resident's bed. b. Review of resident 40's medical record revealed: *Her Brief Interview for Mental Status score was fifteen indicating no cognitive impairment. *She had an above the knee amputation of the left leg. *Her [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus. -Sleep apnea. -Heart failure. -Major [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Gastro-[MEDICAL CONDITION] reflux. -Abnormal posture. -Muscle weakness. *physician's orders [REDACTED]. -Oxygen at 4 liters per minute (lpm) continuous when [MEDICAL CONDITION] not in use. -Oxygen at 10 lpm via [MEDICAL CONDITION] at night and during naps. -[MEDICAL CONDITION] at 16/8 with a backup rate of 12. *physician's orders [REDACTED]. -Oxygen at 2 lpm continuous. -Continue [MEDICAL CONDITION] when sleeping. Observation on 2/27/18 at 3:00 p.m. of resident 40 revealed she had: *Been sitting up in her lift chair taking a nap. *Been using oxygen at 2 lpm. *A [MEDICAL CONDITION] machine on her bedside table. Interview on 2/27/18 at 3:00 p.m. with CNA R regarding resident 40 revealed she used: *Oxygen at 2 lpm during the day. *[MEDICAL CONDITION] at night. Interview on 2/27/18 at 3:15 p.m. with CNA S regarding resident 40 revealed: *She stated I have never seen her wear her [MEDICAL CONDITION] when she takes a nap during the day. *She used oxygen at 2 lpm during the day. Interview and observation on 2/27/18 at 3:30 p.m. with resident 40 revealed: *She had been sitting up in her lift chair and using her oxygen per a nasal cannula. *Oxygen concentrator had been set at 2 lpm. *She stated I only use my oxygen at 2 lpm during the day and 6 lpm with my [MEDICAL CONDITION]. -I have lost weight and my breathing is getting much better. -I only use my [MEDICAL CONDITION] at night. *She no longer took naps in her bed, since she was getting stronger. *Used a stand aid for transfers. *She took her naps in her lift chair. Review of resident 40's (MONTH) (YEAR) and (MONTH) (YEAR) treatment administration record (TAR) revealed: *02 at 10 lpm via [MEDICAL CONDITION] at night and during naps. -Start date 4/27/17. *02 at 4 lpm per nasal cannula continuous when [MEDICAL CONDITION] not in use. -Start date 4/27/17. *Documentation of 02 and [MEDICAL CONDITION] checks from 6 a.m. to 2 a.m., 2 a.m. to 1 p.m., and 10 p.m. Review of resident 40's 2/21/18 revised care plan revealed: I USE OXYGEN AT 10 lpm AT N[NAME] (night) with a Bi-Pap. 02 4 lpm DURING THE DAY. Interview on 2/28/18 at 2:55 p.m. with registered nurse (RN) I regarding resident 40 revealed she: *Used a [MEDICAL CONDITION] device at night with oxygen at 6 lpm bled-in. *Used oxygen at 2 lpm continuous during the day. *Took naps during the day. -Did not use her [MEDICAL CONDITION] for naps. 4. Interview on 3/1/18 at 9:15 a.m. with the director of nurses confirmed: *Resident 25's right heel had not been off-loaded per physician's orders [REDACTED]. *RN I should not have pre-signed for medications. Medications were to have been signed by the RN after they had been given. *UAP A should not have calculated medication doses. -The MAR had not indicated giving two tablets of ranitadine or [MEDICATION NAME] had equaled the croccert dosage. -Medication doses should only have been calculated by a licensed nurse. -UAP A required the supervision of an RN to pass medications. -UAP A should have verified the doses of the above mentioned medications with a RN. Interview on 3/1/18 at 12:27 p.m. with the director of nursing regarding resident 40 revealed: *Her oxygen order had been changed on 2/2/18 to: -Oxygen at 2 lpm continuous. -Continue [MEDICAL CONDITION] when sleeping. *The new order was not changed on the TAR or care plan. -She agreed that should have been changed to reflect the resident's current oxygen orders. *She had been unable to provide an order for [REDACTED]. -Unsure when or why that had been changed. *She planned on calling the [MEDICAL CONDITION] physician for clarification of the following: -Oxygen liter flow for daytime and nighttime. -Oxygen usage for daytime and nighttime. -[MEDICAL CONDITION] usage with or without naps. Review of the provider's last revised 1/2/18 medication aide job description revealed they were to have: *Asked questions, so he/she could understand and support decisions having been made. *Kept direct supervisor informed on necessary information. *Strived to master the skills needed to do the best for the people they cared for. *Consulted with the staff nurse as needed. *Passed routine and as needed medications under the direction of a nurse. Review of provider's revised (MONTH) (YEAR) Physician order [REDACTED]. *To correctly and safely receive and transcribe physician's orders [REDACTED]. *A notation needs to be made in the resident's medical record as to the reason for the new order and a brief summary of what it was. *All transcription of orders should have been signed off by a nurse and double-checked by a second nurse to assure that all steps have been carried out to avoid errors. The second nurse will run the Administration Record Report for the MAR/Tar to view for accuracy of the transcription. Review of the provider's 2014 Medication Administration policy revealed medication should have been signed after it had been given. Review of provider's revised (MONTH) 2014 Physician Services policy revealed: Physician orders [REDACTED]. Review of provider's revised (MONTH) (YEAR) Care Planning policy revealed: *The physician's orders [REDACTED]. *The DON was responsible for updating the care plan. Surveyor: . Review of [NAME] [NAME] Potter et al., Fundamentals of Nursing, 9th Ed., Elsevier, St. Louis, Mo., (YEAR), page 311, revealed: *The physician is responsible for directing medical treatment (311). *Nurses follow care provider's orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient (resident) (311).", "filedate": "2020-09-01"}
{"rowid": 90, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 679, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to provide individualized activities to one of six sampled dependent residents (41). Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had been admitted from the hospital for weakness. *She had been at home prior to that with a care giver. *She had twenty-four falls since her admission on 12/19/17. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. Observation on 2/27/18 at 11:20 a.m. of resident 41 revealed: *She was in her room sitting in her recliner watching the TV. *Her leg was stuck in-between the foot rest of the recliner and the seat. Observation and interview on 2/27/18 at 11:45 a.m. with registered nurse (RN) I regarding resident 41 revealed: *She was lying in her bed. *RN I stated she was told about the resident getting her leg stuck in the recliner. *They were going to remove the recliner from her room due to the incident. *At that time the maintenance director came over to take the recliner out of her room. *RN I stated the resident could not be left alone in her wheelchair without supervision, as she had fallen out of the wheelchair. -She had hit her head as a result of falling out of her wheelchair. Observation on 2/27/18 at 2:10 p.m. of resident 41 revealed she was lying in her bed with no radio or TV on. Observation on 2/27/18 at 4:50 p.m. of resident 41 revealed she was lying in bed with no radio or TV on. She was awake. Observation on 2/27/18 at 6:25 p.m. of resident 41 revealed: *She was lying in bed. *She was attempting to get out of bed. *Both legs were over the scooped mattress. *She was trying to lift her body up. *She was wide awake. *There had been no staff around. Observation on 2/28/18 at 7:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. Observation on 2/28/18 at 8:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. She was slouched over. Observation on 2/28/18 at 8:49 a.m. regarding resident 41 revealed: *She was slouched over in her wheelchair sleeping. *There had been no staff in the area supervising her. Observation on 2/28/18 at 9:02 a.m. of resident 41 revealed she was taken into her room and laid down. Observation on 2/28/18 at 9:27 a.m. of resident 41 revealed she was attempting to get up out of bed. There had been no staff around to witness her attempt at getting up. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: *They checked on resident 41 every two hours to see if she needed to go to the bathroom. *They usually laid her down in between meals. *She is the first one they lay down after breakfast, and the last one to get up before lunch. Observation on 2/28/18 at 10:00 a.m. of resident 41 revealed RN I had been in her room changing her dressings to her heels. She was in a sitting position with her feet hanging over the bed. She was lying back against wall. Interview on 3/01/18 at 9:49 a.m. with the social services designee regarding resident 41 revealed: *She had made a referral to the mental health services in the area. *Her niece wanted her to be moved to another facility, and she was working on that. *There were no other interventions she was attempting with the resident. *There had been no documentation regarding social service interventions. Observation on 3/01/18 at 9:59 a.m. of resident 41 revealed she was lying in bed with both feet hanging off the bed. There were no staff around to see her. The TV and radio were not on. Observation on 3/01/18 at 10:41 a.m. of resident 41 revealed: *She had been lying in bed. *Both legs were hanging off the side of the bed. *The lights were off. *She was awake. Observation on 3/01/18 at 1:02 p.m. of resident 41 revealed she was lying in bed with no TV or radio on. Interview on 3/01/18 at 1:02 p.m. with the recreation services manager regarding resident 41 revealed: *She had not done an assessment upon admission regarding her activity choices or preferences. *Her niece thought she would like BINGO, but the recreation services manager stated she did not think she would like it. *She had not asked the niece about any other likes of the resident. *She thought the resident liked to people watch the most. *She sometimes refused and had not wanted to participate in activities. *She had not been doing one-on-ones with her. *Stated I know we need to do more with her. *The music/radio/TV activity was usually in her room. *The socializing with others activity was at meals. *She was not sure how to print the activities logs for (MONTH) (YEAR) or (MONTH) (YEAR). Review of resident 41's (MONTH) (YEAR) activities documentation revealed: *Her activities included church services, radio/music/TV, friends/family visit, and socializing with others. *She had attended church three times. *She had family or friends visit three times. *She had radio/music/TV marked twenty-five times. *She had socializing with others marked twenty-five times. *There were no other activities documented. Interview on 3/01/18 at 2:03 p.m. with the director of nursing regarding resident 41 revealed they had been laying her down in bed after meals. They had been doing that because she had to be supervised when she was in her wheelchair. She was unsure what activities they had been doing with her.", "filedate": "2020-09-01"}
{"rowid": 91, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 686, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (320) who had a diabetic/pressure ulcer received appropriate dietary interventions and services per the physician's orders [REDACTED]. 1. Interview on 2/27/18 at 8:10 a.m. with licensed practical nurse (LPN) C regarding resident 320 revealed: *He: -Had been admitted on [DATE] from an acute care setting. -Was diabetic and had been admitted with two wounds. *She stated He has a black wound to the tip of his right second toe and a small scrape behind his left ankle. -He had a daily dressing change for the wound to his right second toe. -The dressing on his left ankle was changed every three days. *She was unsure how he had gotten the wounds. Observation and interview on 2/27/18 at 8:40 a.m. of resident 320 revealed: *He had: -Been in his room sitting on the edge of the bed. -Been wearing a nasal canula that was hooked up to an oxygen concentrator and running at 2 liters per minutes (LPM). -Gripper socks on his feet. *He stated: -I was in really poor condition when I went to the hospital. -I'm a diabetic and my sugars were very high. -My goal is to go home here really soon. *He had a wound on the tip of his right toe and left ankle. *He stated: -I've been told my toe is a diabetic ulcer. -I fell at the hospital and scraped my left ankle. Observation on 2/27/18 at 12:46 p.m. with LPN C during a dressing change with resident 320 revealed: *She had: -Prepared to change the dressing on his right second toe. -Removed the old dressing and exposed the wound on his toe. *The tip of the resident's toe had been: -Contracted at the first joint, so the tip was in the downward position. -Covered with a brown colored scab. --That scab measured approximately 0.5 centimeters (cm) by 0.5 cm in diameter. *She assessed, cleaned, and applied a new dressing to that wound. *The resident stated: I think it came from a shoe, but I'm not sure. Review of resident 320's medical record with the Minimum Data Set (MDS) assessment coordinator revealed: *On 2/21/18: -He had been readmitted to the facility from an acute care setting. -The staff had completed an admission physical assessment of his skin and documented Small black scab to tip R (right) foot 2nd toes, black ulcer intact and dry, observing for any changes. *[DIAGNOSES REDACTED]. *He was: -Alert, oriented, and had good memory recall. -Working with the therapy department to improve his strength, safety, and independence with the goal to return home. *On 2/22/18 the physician had: -Been in the facility to assess the resident and review his orders from the hospital. -Written orders for [MEDICATION NAME] to be applied to his toe daily. -Referred the resident to the dietary department for education and nutritional support. -Not provided a [DIAGNOSES REDACTED]. *No documentation to support the dietary department had been notified of the wound to his right toe per physician's orders [REDACTED]. Review of resident 320's 2/21/18 through 2/28/18 daily skilled progress notes with the MDS assessment coordinator revealed: *There was no consistent charting to identity the type of wound the resident had on his right second toe. *The nursing staff had randomly charted the wound as a: -Small, shallow, black scab. -Black ulcer. -Pressure ulcer. -Dark/black area/pressure sore on second toe right foot. -Diabetic sore 2nd toe on the right. *No documentation: -To support the dietary department had been notified of his wound. -By the dietary manager or the dietician to support nutritional involvement or knowledge of that wound. Review of resident 320's 2/28/18 skilled status assessment with the MDS assessment coordinator revealed the wound to his right second toe was assessed and documented as a diabetic ulcer by the director of nursing (DON). Review of resident 320's 2/23/18 admission care plan with the MDS assessment coordinator revealed: *A focus area: I am at nutritional risk. -Goal was: --I wish to have my nutritional and hydration needs met so that I do not suffer from dehydration, significant weight changes, and/or skin breakdown. --No goal identifying a wound or ulcer to his right second toe. *There had been no nutritional interventions in place to support and promote healing of an ulcer or wound to his right toe. Interview on 2/28/18 at 4:01 p.m. with the dietician and MDS assessment coordinator revealed: *He had not been aware the resident had an ulcer to his right toe until 2/27/18. -The director of nursing (DON) had emailed him their weekly wound report. --That report supported a diabetic ulcer on the resident's toe. -He would not have expected to be notified of a diabetic ulcer. -He stated: --There is really nothing I can do for a vascular wound, but a stage two or greater pressure ulcer absolutely. --I talked to the resident and looked at his toe, it is deformed, and the resident said it is a diabetic ulcer. *He would have expected the staff to notify him of a pressure ulcer. *He was available to the staff and dietary manager via email or phone on the days he was not in the facility. Interview on 2/28/18 from 3:37 p.m. through 4:13 p.m. with the MDS assessment coordinator after review of resident 320's medical record revealed she: *Agreed the nursing staff: -Could not [DIAGNOSES REDACTED]. -Had the capability to assess, document, and stage a pressure ulcer. -Should have clarified with the physician what type of ulcer the resident had on his right toe on 2/22/18. *Agreed the physician should have documented what type of ulcer the resident had on his toe. *She confirmed there was no documentation to support the dietary department had been aware of an ulcer to his right toe. *She confirmed: -There was no physician progress notes [REDACTED]. -She stated: --The doctor does not have progress notes in any of the resident's charts. --There are some notes hand written on the physician's orders [REDACTED]. --The progress notes are dictated, but we have printing issues and we can't print them. --I believe we don't have access to their new system at the clinic. Interview on 3/1/18 at 11:15 a.m. with the dietary manager regarding resident 320 revealed: *She had not been aware he had an ulcer to his right toe. *The department managers had stand-up meetings every week day morning. -Wounds would have been discussed at that meeting. *She: -Would have handwritten any pertinent notes for the dietary department during those meetings. -Had no documentation on any of her handwritten notes from the past week to support knowledge of a wound to the resident's right toe. -Confirmed the dietician was available via email or phone when he was not in the facility to address any nutritional concerns. -Would not confirm whether the dietary department should have been notified of all types of wounds and ulcers to ensure adequate nutritional support. Interview on 3/1/18 at 1:20 p.m. with the DON and physician regarding resident 320 revealed: *The physician confirmed her visit and assessment with the resident on 2/22/18. *She had been aware of the wound to his right second toe. *She agreed: -Her assessment and documentation on the physician's orders [REDACTED]. -The nursing staff could not [DIAGNOSES REDACTED]. *She stated: -But I don't care what type of ulcer it is the dietary department should be involved with any and all types of ulcers. -His toe is both a diabetic and pressure ulcer due to the deformity of it, his [MEDICAL CONDITION] problems, and possible pressure from his shoes. -He specifically requested dietary education and support, because he is diabetic, has [MEDICAL CONDITION], and will be going home soon. -Its crucial to have that nutritional support and involvement because of his [MEDICAL CONDITION] and the potential of that wound to worsen when he goes home. -I expected the dietary department to have been notified per my orders. *She confirmed: -She wrote a brief and shorthand note on all the resident's physician's orders [REDACTED]. -She had dictated her progress notes, and they could not be found in the residents' charts. *She stated: -In (MONTH) we went to a different system and the nursing home cannot access them and print them now. -The clinic can print them, we will have to start printing them, and getting them to the facility. *The DON: -Confirmed: --The department heads had a daily stand-up meeting on the weekdays, and wounds were discussed at that time. --The dietary manager would have attended all of those meetings. -She stated: -We reviewed that resident in stand-up after he was admitted , and the dietary manager was there. -I personally myself told the dietician about it. -Had a form dated 2/23/18 from that morning stand-up meeting. --The resident's name had been written down on that form to review for skin concerns that day. -Confirmed the dietician had been emailed the weekly wound form on 2/27/18. -Was unable to locate any documentation to support her conversation with the dietician regarding the resident's ulcer prior to 2/27/18. Review of resident 320's 2/22/18 physician's visit progress note revealed: *He had: -Type 2 diabetes with multiple complications including [MEDICAL CONDITION]. -A right second toe shallow diabetic ulcer. -Been referred to dietary for nutritional education and support. *It was not available for review by the staff, and a part of his medical record until 3/1/18 after the surveyor requested to review it. Review of the provider's (MONTH) (YEAR) Skin Program policy revealed: *Policy: To provide care and services to promote the healing of pressure ulcers/wounds that are present. *Procedure: -Nursing personnel will utilize the results of the physical exam and the Pressure Ulcer Assessment tools to determine an individualized pressure ulcer prevention program for each at-risk resident. -This will include interventions to encourage optimal nutrition and fluid intake. *When a skin ulcer is identified. This assessment will include: Type of skin ulcer (MD (medical doctor) is asked to identify type of ulcer, e.g., pressure, stasis (venous, ischemic (arterial), or neuropathic, and provide skin treatment orders. *Nursing personnel will develop a P[NAME] (plan of care) with interventions consistent with resident and family preferences, goals, and abilities. -P[NAME] to include nutritional status and interventions.", "filedate": "2020-09-01"}
{"rowid": 92, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 688, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure a functional restorative therapy program was in place for one of three sampled residents (61) residents who had contractures. Findings include: 1. Observation and interview on 2/27/18 at 8:05 a.m. with resident 61 revealed: *Both hands had observable contractures. -Her left hand side fingers were touching the palms of her hand, and her wrist had contracted toward her forearm. -Her right hand and wrist were slightly less contracted than her left side. *The left arm had been tight against her chest. -A contracture in her left elbow made it impossible for her arm to be straightened. *Her head angled toward the right due to contracture. -She could stretch it toward the left with much effort. *Both legs were unable to lay completely straight due to contracture. *She stated she was unhappy with therapy services. -She would like to walk again but understood she was a long way from that. -She stated her contractures were getting worse. --Her hands, neck, and legs felt tight. --Stretching made it feel better. *She stated she would enjoy more restorative therapy if it were offered. Review of the 3/1/18 physician's orders [REDACTED].>*[DIAGNOSES REDACTED]. *Pain medications included: a [MEDICATION NAME] every seventy-two hours, and as needed [MEDICATION NAME] suppository, [MEDICATION NAME] tablet, and [MEDICATION NAME]-[MEDICATION NAME] tablets. Review of her 2/13/18 care plan revealed: *A focus area of: I am at risk for contractures. *A goal of: I will participate with Restorative Therapy through next review to maintain ROM (range of motion) to UE's (upper extremities), LE's (lower extremities), and neck 2-3x/wk (times per week). 5-10 reps. (repetitions) to prevent further contractures for ADL (activities of daily living) functioning. *Interventions of: Passive ROM to both UE's and LE's 5-10 reps. while in supine or w/c (wheelchair). Passive stretch to neck right side bending, 1-5 mins. 2-3x/wk. *A second focus area of: I am at risk for a decline in function. *The goals were: I will participate in my restorative program for PROM (passive range of motion) stretching 10-15 minutes 2-3 x a week. *The interventions were: Nursing Rehab: PROM to both upper and lower extremities, passive neck stretch to right neutral 10-15 minutes 2-3 x a week. Review of 1/30/18 through 2/27/18 task documentation titled nursing rehab revealed: *Instructions had been to perform passive range of motion to both upper and lower extremities, passive neck stretch to right neutral with five to ten repetitions; two to three times a week revealed: -Resident had completed care/training as directed. Review of the (YEAR) quarterly physical therapy (PT) screen forms revealed: *A 2/13/17 order for PT to improve head position during meals. *A 6/26/17 screen stated no change, and that PT evaluation had not been indicated. *A 9/13/17 screen stated no new complaints of positioning. *An 11/7/17 PT evaluation stated to re-establish the restorative program after return to long term care from hospital. Review of the 11/7/17 occupational therapy (OT) evaluation revealed a recommendation of placing a washcloth roll in her left hand. And to resume the range of motion program for the restorative nursing program. Interview on 2/28/18 at 9:41 a.m. with the director of nursing (DON) revealed: *The current process for placing a resident on a restorative nursing program consisted of the OT and the PT completing an initial evaluation. *Each therapist would then create recommendations for a restorative nursing program. *Those recommendations would be discussed with the restorative supervisor who was a certified nursing assistant (CNA). *The restorative supervisor would discuss the recommendations with the DON to determine a realistic individualized restorative nursing program. *She would review the restorative supervisor's monthly program review for each resident and decide if the resident's restorative program should be changed or stay the same. -Review of resident 61's program revealed no changes had been made. *She had not been told that resident felt her contractures had gotten worse. -She felt the resident's contractures had remained the same and had not worsened. *There was only one restorative aide, so they had to consider that when creating each restorative program. *She did not feel CNA's could provide passive range of motion stretches due to time constraints. Interview on 2/28/18 at 2:10 p.m. with resident 61 revealed: *She had been lying down in bed with a rolled washcloth partially in her hand. *According to her: -That was to prevent her fingernails from pushing into the palm of her hand. -It was also to prevent her contracture from getting worse. *She said she used to wear a brace. *She stated she did not always get therapy two to three times a week. -It was usually in the mornings. -If there were not enough staff she might not get therapy. *She sometimes tried to do her own stretches. - Using her right hand she demonstrated by pushing her left hand and arm to stretch it herself. --Her ability to do that had been very limited. Interview on 2/28/18 at 2:15 p.m. with restorative supervisor/CNA O revealed: *She did passive range of motion exercises with resident 61 three to four times per week. *Her day started at 4:00 a.m. to get everyone done per their preferences. *Resident 61 had not complained to her about pain or contractures worsening. -If she had known that she would have reported it to her supervisor for an evaluation. *She was the only restorative aide. -Her schedule was four days per week. -There were forty residents on her caseload. *She did not feel resident 61's contractures had worsened. -Her supervisor, the DON, had completed monthly reviews of all residents on her caseload for apprporiateness on the restorative therapy program. *If a resident needed more days of restorative therapy she would have needed to work longer days to get everything done. Interview on 2/28/18 at 2:20 p.m. with PT revealed: *He completed a screen with each quarterly MDS. *He would get information from residents when possible and from staff. *If a resident was worsening or had a change of condition they could screen any time, they did not need to wait until the quarterly screen. -He would then decide if he could work with her on the physical therapy program, or if he would recommend her for the restorative therapy program. *He worked closely with the restorative aide and nursing to set recommendations. *He agreed that current restorative aide had a large caseload. *He had not heard that resident 61 had a concern. -He would talk to her. *He had seen her twice during the past year. -He had completed an evaluation after her last hospitalization that had been from 10/20/17 to 11/6/17. Interview on 3/01/18 at 3:21 p.m. with the DON and the medical consultant revealed: *They had been unaware of resident 61's wish to receive more restorative therapy. *They were unaware that she had any concerns regarding her restorative therapy program or her contractures. *The DON completed monthly reviews of all residents on the restoative therapy program caseload for apprporiateness. *Both acknowledged that if the resident were to request more services they would need to review her current services for appropriateness. Review of (MONTH) (YEAR) Restorative Nursing Program policy revealed: *The concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.", "filedate": "2020-09-01"}
{"rowid": 93, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 689, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to have adequate supervision and interventions in place for one of one sampled resident (41) with multiple falls occurring in the facility and resulting in two major injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had been admitted for weakness from the hospital. *She had been at home prior to that with a care giver. *She had been identified at risk for falls during her admission assessment. *The 12/19/17 fall risk assessment score was twenty-one. -A score of ten or above indicated a risk of falling. -They were to implement the fall prevention protocol and place approaches in the plan of care. --The fall prevention protocol initiated had been: Resident is very confused. She was orientated to call light but does not appear to know how to use this. She will be working with therapy. Will initiate low bed/mat. *She had twenty-four falls since her admission on 12/19/17. -Two of those falls had resulted in major injury, a [MEDICAL CONDITION] on 1/14/18 and a head injury on 2/22/18. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. *She had verbal behaviors that had occurred one-to-three days during the assessment period. *She had not rejected care during the assessment period. *She required assistance of one staff member for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Locomotion off the unit. -Toilet use. -Dressing. -Personal hygiene. *Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -Diabetes. -[MEDICAL CONDITION]. *She had a fall prior to admission. *She had one fall with no injury since admission. Review of resident 41's 1/26/18 MDS assessment revealed: *Her BIMS score was zero indicating she had severe cognitive impairment. *She had no behaviors. *She had rejected care one-to-three days during the assessment period. *She required extensive assistance of two staff members for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Toilet use. *She required assistance of one staff member for the following: -Locomotion off the unit. -Dressing. -Personal hygiene. *Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -[MEDICAL CONDITIONS]. -Diabetes. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. *They had documented no falls since admission or prior assessment. Review of resident 41's fall scene investigation reports from 12/19/17 through 2/28/18 revealed she had eight unwitnessed falls. Refer to F610, finding 1. Review of resident 41's fall scene investigation reports revealed the following witnessed falls: *On 12/29/17 she had a witnessed fall at 2:30 p.m. that stated resident lost balance. -She had been alone and unattended. -The last time toileted had a question mark in the box. -Conclusion had been Is working with therapy cont (continue) with hourly checks. Ensure call light is within reach. -There had been no additional care plan updates documented. *On 12/31/17 she had a fall in the open court area at 9:30 a.m. -She had been sitting in her wheelchair. -She stated her butt keeps sliding to edge of wheelchair. -Root cause: Cushion in wheelchair slick. Resident keeps sliding to edge of wheelchair seat. -Initial interventions to prevent future falls had been Staff to monitor positioning. -Additional care plan updates had been Ensure cushion has cover and is hooked to wheelchair. Therapy looking to adjust w/c (wheelchair). Review of resident 41's interdisciplinary notes from 12/19/17 through 2/27/18 revealed: *She had also fallen on the following dates: -1/2/18. -1/3/18 a third time. -1/4/18. -1/5/18 two times. -1/6/17. -1/27/18. -1/28/18. -2/1/18. -2/2/18 two times. -2/5/18. -2/6/18. -2/7/18. *There had been no fall scene investigation reports for the above falls. Review of resident 41's current undated care plan revealed: *There had been no intervention to check on her hourly per the above 1/10/18 intervention. *Her toileting plan had been to toilet every two hours. *There had been no interventions regarding an individualized toileting plan. *Interventions in place were initiated after the falls had occurred and not prior. Observation and interview on 2/27/18 at 11:20 a.m. of resident 41 revealed: *She had been sitting in her recliner in her room with the TV on. *She had a green/yellow bruise under her right eye and a two-inch bandage on her forehead. *Her left leg was stuck in-between the recliner seat and the foot rest. *The gap between the two areas had been approximately four inches. *She asked to have her slipper put on. -She seemed unaware her leg was stuck. *She was told her leg needed to be unstuck from the chair. *She stated Oh no can you put on my slipper. *She attempted to pull her leg out from between the gap but was not successful. *She could not put her call light on when asked to, and she just looked at it. -The surveyor put her call light on. *The resident grimaced when she attempted to move her leg. *No one had come to her room. -An unidentified activities staff member was doing an activity in the common area and was asked if there were staff around who could assist the resident. *She stated she was not sure and looked around the area. *She then pointed out a certified nursing assistant (CNA) on the south end of the common area. *The staff member was asked if she had gotten a page for room [ROOM NUMBER]. *She stated she was not wearing a pager. *She came to assist resident 41, and when she saw the residents leg stuck stated Oh wow! *She then used her walkie talkie to call another CNA as her partner on that hall had been on break. -The CNA she called stated she would be down after she helped another resident. *The CNA in resident 41's room assisted the resident by herself and pulled her leg out of the gap. *She then left the room. Observation and interview on 2/27/18 at 11:45 a.m. with registered nurse (RN) I regarding resident 41 revealed: *The resident was lying in her bed. *RN I stated she was told about the resident getting her leg stuck in the recliner. *They were going to remove the recliner from her room due to the incident. *At that time the maintenance director came over to take the recliner out of her room. *RN I stated the resident can not be left alone in her wheelchair without supervision, as she had fallen out of the wheelchair. -She had hit her head as a result of falling out of her wheelchair. Observation on 2/27/18 at 12:30 p.m. of resident 41 in the dining room revealed: *She had been pushed up to the table. *Her foot pedals had been angled up. *She had not been able to get up to the table due to the foot pedals being angled up. *The foot pedals hit the tablemate to her right when she was pushed closer to the table. Interview on 2/27/18 at 12:40 p.m. with CNA P revealed: *They had tried to put the foot pedals down in her w/c, but she was not sure why they left them up. *She went over and took the pedals off and pushed her closer to the table. *Recreation services aide Q stated she had not known the foot pedals were to come off. Observation on 2/27/18 at 2:10 p.m. and again at 4:50 p.m. of resident 41 revealed she was lying in bed. The recliner had been taken out of her room and not replaced. Observation on 2/27/18 at 6:25 p.m. of resident 41 revealed: *She had been lying in bed. *She was attempting to get out of bed. *Both her legs were over the scooped mattress. *She was trying to lift her body up to get out of bed. *She was wide awake. *There were no CNAs in the area. -The director of nursing (DON) was found and the above situation was explained to her. Observation on 2/28/18 at 7:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. There were no staff in the common area. Observation on 2/28/18 at 8:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. She was slouched over. The leg pedals were angled up. Observation on 2/28/18 at 8:49 a.m. regarding resident 41 revealed: *She was slouched over in her wheelchair sleeping. *There had been no staff in the area supervising her. *The leg pedals were angled up. Observation on 2/28/18 at 9:02 a.m. of resident 41 revealed she was taken into her room and laid down. Observation on 2/28/18 at 9:27 a.m. of resident 41 revealed she was attempting to get up out of bed. There had been no staff around to witness her attempt at getting up. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: *They checked on resident 41 every two hours to see if she needed to go to the bathroom. *They usually laid her down in between meals. *She is the first one they lay down after breakfast, and the last one to get up before lunch. *She had been the only CNA on the 300 hall at that time due to her partner being on break. Observation on 2/28/18 at 10:00 a.m. of resident 41 revealed RN I had been in her room changing her dressings to her heels. She was in a sitting position with her feet hanging over the bed. She was lying back against wall. Observation on 3/01/18 at 9:59 a.m. of resident 41 revealed she was lying in bed with both feet hanging off the bed and heel protectors on. There were no staff around to observe her. Observation on 3/01/18 at 10:41 a.m. of resident 41 revealed she had been lying in bed. Both legs were hanging off the side of the bed. The lights were off. She was awake. Interview on 3/01/18 at 2:03 p.m. with the DON regarding resident 41 revealed: *They were putting her in bed between meals, because she had to be supervised if she was up in her chair. *They had not attempted an individualized bathrooming schedule for her. *The CNAs only documented one time per shift that they toileted the resident. *The fall interventions had been implemented after falls had occurred and not before for her. Review of the provider's (MONTH) (YEAR) Fall Prevention policy revealed: *A fall risk assessment will be completed at the following times: -Upon admission/readmission to the facility. -Quarterly - can complete a quarterly review instead of full assessment if no change since previous assessment. -Prior to the annual MDS. -Change of condition. *Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs and as needed. *Incident report and a fall scene investigation form will be completed after fall. *Falls will automatically be logged through completion of Incident Report in PCC (point click care).", "filedate": "2020-09-01"}
{"rowid": 94, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 725, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "Based on observation, interview, and record review, the provider failed to ensure sufficient nursing staff were available to ensure: *One of three sampled residents (61) received restorative therapy. *One of one sampled resident (41) with multiple falls had been supervised. *Call lights were answered timely to ensure resident needs were met. Findings include: 1. Interview with resident 61 revealed the facility failed to provide her with restorative therapy on a regular basis. Refer to F688, finding 1. 2. Review of resident 41's medical record revealed she had twenty-four falls since her admission on 12/19/17. Refer to F689, finding 1. 3. Resident council meeting on 2/27/18 at 2:25 p.m. with a group of residents and two family members revealed: *They had concerns with the call light wait times. *Staff would come in the room, turn off the call light, and say they would come back later. -They would not always come back. *The wait times got better for a little while but had gotten bad again. Review of the (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) resident council minutes revealed concerns had been brought up about long call light wait times. Refer to F919, finding 3.", "filedate": "2020-09-01"}
{"rowid": 95, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 759, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure two of two randomly observed residents' (40 and 56) insulin had been administered according to policy and procedure by one of one licensed practical nurse (LPN) (B). Those observations created a medication error rate of 12.9 %. Findings include: 1. Observation and interview on 2/28/18 from 7:40 a.m. through 7:50 a.m. with LPN B revealed: *During resident 26's [MEDICATION NAME]pen administration she had not held the needle into the resident's skin for more then two seconds after administration and prior to removing it. *During resident 56's administration of the following insulins revealed:-[MEDICATION NAME] 1.8 milligram per 3 ml insulin pen administration. -[MEDICATION NAME] 40 units insulin pen. -[MEDICATION NAME] 7 units insulin pen. She had not held the needles into the resident's skin more than two seconds after administration and prior to removing them. Sherevealed it had been her usual practice to leave the insulin pen in place for only two seconds after injecting the medication. She stated she counted one-thousand-one and one-thousand-two then removed the needle. Interview on 3/1/18 at 8:45 a.m. with the director of nurses revealed: *The above practice by LPN B had been wrong. *Insulin injection pens should have remained inserted in the skin for at least five seconds. Review of the provider's last revised (MONTH) (YEAR) Insulin and Non-Insulin Pen Delivery Systems policy and procedure revealed: *The length of insulin injection times were to have been: -[MEDICATION NAME] 6 seconds. -[MEDICATION NAME] 6 seconds. -[MEDICATION NAME] 6 seconds. *Dose buttons should be pressed down and needle kept under the skin for a full count of seconds to insure the full dose is injected.", "filedate": "2020-09-01"}
{"rowid": 96, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 880, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure: *The Hoyer lift on the 200 hall had cleanable surfaces. *One of one randomly observed resident (10) had clean and unworn hell protector boots. *A bedpan and graduate pitcher in room [ROOM NUMBER] had been stored in a sanitary manner. *A sanitary environment was maintained for: -The storage of resident use equipment in one of one bathroom located on the Transitional Care Unit (TCU). -One of two sampled resident's (320) oxygen tubing when not in use. -The placement of a urinal after it was used for one of one sampled resident (321). -The placement of resident personal care products in two of five randomly observed resident's rooms (110 and 113). -The storage of juice containers in one of one kitchenette on the TCU for one of one juice machine. -The filters in five of five hairdryers located in the main sitting/visiting area on the 300 wing. -One storage room on the 400 wing. Findings include: 1. Observation on 2/27/18 at 11:27 a.m. of the 200 hall Hoyer lift revealed it had a blue fabric and foam covering over the bar where the slings hooked. That covering was opened approximately six inches and had exposed yellow foam poking out. That foam would be uncleanable. 2. Observation on 2/27/28 at 11:35 a.m. of resident 10 revealed she had on heel protector boots. Those boots had Velcro closures. The fabric around the Velcro and on the top and sides of those boots was torn and worn. It was an uncleanable surface. 3. Observation on 3/1/18 at 8:15 a.m. of the bathroom in resident room [ROOM NUMBER] revealed a wash basin and bedpan sitting on the floor directly below the sink. There had been no covering or barriers in place to protect those items from contamination from the floor. 4. Interview on 3/1/18 at 8:45 a.m. with the director of nurses (DON) revealed she agreed: *The padding on the Hoyer lift bar needed replacing and had been an uncleanable surface. *Resident 10's heel protector boots needed to be replaced and had been uncleanable. *The wash basin and bedpan should not have been on the floor in resident room [ROOM NUMBER]'s bathroom. Review of the provider's last revised (MONTH) (YEAR) Laundry and Linen policy revealed all washable residents' personal equipment would be laundered if soiled. 5. Observation on 2/27/18 at 11:05 a.m. of a bathroom on the TCU located across from the therapy department revealed: *The bathroom with a toilet, sink, and bathtub had been identified as a shared female/male bathroom by a sign attached to the door. *There had been several types of resident use equipment stored in that bathroom such as: -A wheelchair (w/c) weighing scale. -A large wooden mirror that had wheels on the bottom of it for movability. -Two small plastic bins sitting directly on the floor next to the bathtub. -A shower chair. -A w/c. -Several walkers hanging on hooks. -A red therapy bolster sitting directly on the floor. -Two large bouncy balls located on a shelf above the walkers. Interview on 2/27/18 at 11:10 a.m. with speech therapist (H) regarding the above observation revealed she: *Had been unsure: -What the bathroom was used for. -If the bathroom was used for storage or not. *Stated But I know the visitors use that for a bathroom. Observation and interview on 2/27/18 at 11:44 a.m. with the administrator regarding the TCU bathroom revealed she: *Had been unaware that: -Visitors had been using that bathroom. -The staff had been storing resident use equipment in that bathroom. *Stated: -Visitors should not be using that bathroom. -Staff shouldn't be storing equipment in there. -That bathroom is to be used by therapy with the residents for training purposes only. *Agreed with visitors using the bathroom they could not guarantee the equipment that was stored in there was kept clean. Observation and interview on 2/27/18 at 2:00 p.m. with physical therapist (PT) G regarding the TCU bathroom revealed he: *Had been aware that visitors used that bathroom. *Had been aware resident equipment was stored in that bathroom. *Stated: -The staff use it as well. Its the only bathroom close to this area. -We mostly use the bathtub when working with residents who are going home and have a bathtub. *He agreed: -The equipment was not stored in a clean environment. -That process had created the potential for bacteria to spread from one person to another. 6. Random observations on 2/27/18 from 8:00 a.m. through 3:13 p.m. of resident 320's oxygen tubing revealed: *The resident had been observed using: -His oxygen continuously throughout the day. -An oxygen concentrator when he was in his room. -A portable oxygen tank when not in his room. *At 8:46 a.m. the: -Resident had been in his room and was using the oxygen concentrator. -Portable oxygen tank had been hanging from his walker. -The oxygen tubing attached to that portable tank was on the floor and underneath of his bed. *At 12:51 p.m. revealed the same observation as above. *At 3:08 p.m. the: -Resident had been in the therapy room and was using his portable oxygen tank. -Oxygen tubing attached to the concentrator in his room was lying directly on the floor. Observation and interview on 2/28/18 at 8:35 a.m. with certified nursing assistant (CNA) (D) regarding resident 320's oxygen tubing revealed: *She had not been aware the resident was leaving his oxygen tubing on the floor when not in use. *She stated They usually have a bag attached to the walker and concentrator to put them in. -The concentrator had a bag attached to it, but the walker did not. *The resident had been in the room, and he: -Was not aware that storing the oxygen tubing on the floor when not in use was unsanitary. -Had never been educated by the staff of a different process. *She agreed the process above: -Was not completed in a sanitary manner. -Created the potential for the spread of bacteria to the resident. 7. Random observations on 2/27/18 from 7:55 a.m. through 4:27 p.m. of resident 321 revealed: *He had: -Been admitted from the hospital after having a stroke. --That stroke had caused him to have [MEDICAL CONDITION] on the right side of his body. -Required staff assistance with all activities of daily living (ADL). -Remained continent of urine with the use of a urinal. -Been able to use that urinal independently. -Stored the urinal on his bedside table by his water glass, Kleenex, and other various personal items. -Required the staff to empty the urinal for him after he had used it. *During the above time frame the resident had used the urinal twice. -Both of those times he had: --Filled the urinal a quarter full of urine and placed it on the bedside table for the staff to empty. --Not called the staff to empty the urinal after he used it. *At 4:27 p.m.: -Licensed practical nurse (LPN) C had administered medication to the resident in his room. -He had recently used the urinal, and it was a quarter full of urine. -He had placed the urinal on his bedside table by his water glass and Kleenex. -LPN C administered him the medication and left the room without emptying his urinal. Interview on 2/28/18 at 8:32 a.m. with CNA D regarding resident 321's urinal revealed: *She had been aware the resident placed his urinal on the bedside table. *She confirmed the resident: -Was dependent upon the staff to empty his urinal. -Would not call the staff to empty it after he had used it. -Was alert, oriented, and capable of being educated on a better process for placing/storing his urinal. *The staff had not worked with the resident to see where he could have placed the urinal and still have access to it without difficulty. *She agreed the placement of his urinal was not considered a sanitary process. 8. Random observations on 2/27/18 from 10:36 a.m. through 10:46 a.m. of resident rooms [ROOM NUMBERS] revealed: *Both rooms had large plastic containers sitting on top of the counters by the sinks. *Those containers had various personal healthcare products inside of them such as: -Open bars of soap. -Combs and brushes with hair inside of them. -Packages of wet wipes. -A plastic bag containing used roll of tape inside of it. -Tubes of toothpaste. -Toothbrushes with their bristles unprotected and resting right next to the above items. Observation and interview on 2/28/18 at 8:40 a.m. with CNA D regarding the plastic containers in residents' rooms [ROOM NUMBERS] revealed she: *Confirmed there were personal care products mixed together inside of those plastic containers. *Agreed: -The personal care products should not have been stored together like that. -Mixing those personal care products together had not been a sanitary process. *Stated The toothbrushes should not be stored in there with all of this stuff. 9. Observation on 2/27/18 at 12:15 p.m. of the kitchenette area in the TCU revealed: *There was a juice machine sitting on top of the counter. *Above and below the juice machine was cabinetry with several drawers and doors. *The juice containers that were connected to the juice machine for dispensing were located on a shelf inside of the cabinet below the machine. *The shelf the juice containers were stored on was covered and dirty with thick/gray colored lint particles. Interview on 2/27/18 at the time of the above observation with CNA D revealed: *The staff who worked in the TCU were responsible for the cleaning of the kitchenette area. *There was no specific cleaning schedule for them to follow. *The juice machine had been purchased less than a week ago. *The storing of the containers in the cabinet below was a new process for them. *She agreed the: -Shelf was dirty, and it would have taken longer than a week for that amount of lint build-up. -Placement of those juice containers had not been done in a sanitary manner. -Kitchenette area was to have been as clean as possible to ensure the delivery of food/drinks was done in a safe and sanitary manner. 10. Observation on 2/28/18 at 7:55 a.m. in the sitting area of the 300 wing revealed: *There had been several recliners/chairs located in that area. *Mixed in between those recliners/chairs were five hairdryers. *All five of those hairdryers had lint filters attached to the back of them. *Those filters had: -Been full of a grayish/white colored particle. -Created a small dust ball in the air when pulled out of the hairdryers. 11. Interview on 3/8/18 at 9:41 a.m. with the director of nursing and administrator revealed: *They had not been aware of all the concerns and break in sanitary processes identified above. *They were not sure: -If the hairdryers belonged to the beautician or were owned by the facility. -Who should have been responsible to ensure the filters on the hairdryers had been kept clean. *They agreed the processes above were unsanitary and created the potential for bacteria to have spread to the residents. Review of the provider's (MONTH) 2013 Care and Storage of Resident Personal Care Items policy revealed: *Policy: To assist in the prevention of the spread of infection by assuming resident personal care items are kept clean and stored in the resident's personal area. *Procedures: -Personal care items will be stored in a non-communal area. E.[NAME] such as a toothbrush in a holder. -Items will be placed in a drawer of resident's bedside table in a basin, or in a plastic bag away from other personal care items. -If a personal care item is found to be left out in the resident's bathroom or on top of a nightstand or other area where the sanitation is questionable, it will be discarded and replaced with a new one, or if cleanable, will be disinfected prior to return to storage area. On 2/28/18 at 2:00 p.m. a list of policies and procedures were given to the administrative department and had been requested: *Use of a urinal. *Storage of resident use equipment. *TCU kitchenette cleaning of cabinets/area. *Oxygen tubing placement when attached to concentrators/portable oxygen canisters and not in use. *Those above policies were not provided to the surveyor prior to exit of the facility. Observation on 2/27/18 at 8:30 a.m. of the storage room located on the 400 wing revealed: *The room had been used for mechanical lift storage, five oxygen concentrators, four lift batteries were located on a shelf, one electric scooter with a liquid oxygen cylinder attached, a shower bench, a commode, and other miscellaneous items. *Each wall had chipped paint with the highest concentration being along the bottom of each wall. *There had been scuff marks on all lower walls. *A crack in the exterior wall had been visible under the lower left corner of the window. *There was a door inside this storage room that stated housekeeping supplies. -The door had four areas along the edge which had the top layer of wood missing. --These areas were approximately a quarter in diameter each. -The lower area of the door had two holes. --Each of these holes were approximately the size of a quarter. Interview on 2/28/18 at 9:41 a.m. with the director of nursing revealed: *The storage room walls and door to housekeeping supply area were in need repair. *She agreed they would be considered unable to be cleaned. *She stated it would be maintenance's responsibility to complete these repairs. Observation and interview on 3/01/18 at 3:05 p.m. with the maintenance director revealed: *The storage room down the 400 wing was in need of a new door for the housekeeping supply area. *The walls were in need of repair and paint. *He stated they repair and/or paint four to five rooms per year and prioritize resident rooms before other areas. *He does not want other rooms to be neglected but always tries to do resident rooms first. *This room is on his list for this year. -There is no actual list. It is just on his mind to get done. *He does not have any type of policy regarding when to repair or paint rooms. -He does have a preventative maintenance program for equipment but not for something like this. Observation and interview on 3/01/18 at 3:20 p.m. with the administrator and the medical consultant revealed: *A walk through inspection of the storage room located on the 400 wing had chipped paint on every wall. -The housekeeping storage door located inside the storage room had gouges in the wood. -The room was in need of paint and repair. *Both agreed it would be considered unable to be cleaned.", "filedate": "2020-09-01"}
{"rowid": 97, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 909, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and manufacturer's manual review, revealed the provider failed to assess the safety for one of one sampled resident's (320) mattress to ensure it was secured to the bed frame and free from unsafe movement. Findings include: 1. Observation and interview on 2/27/18 at 8:57 a.m. with resident 320 revealed: *He had been: -Located in the transitional care unit (TCU). -Sitting on the edge of his bed. *The repositioning bar had been in the down position on the right side of his bed. *The left side of his bed had been placed against the wall. *The bed frame had: -Been exposed underneath of his right leg. -Long metal brackets attached to each end of it. --Those metal brackets were used to secure the mattress in place. *His mattress was not secured in place by those brackets and had shifted sideways on the bed frame. -That movement had created the bed frame to be exposed underneath of his leg by approximately 2 to 3 inches in width. *He confirmed: -He was independent in his room and could transfer himself on and off of the bed. -The mattress had shifted and moved around on the bed frame since he was admitted on [DATE]. *He stated They did offer me another bed, but I refused it as I didn't want to cause any problems. *He denied any injury from the exposed bed frame. Observation on 2/27/18 at 11:50 a.m. of resident 320 revealed: *The resident had just returned from working with therapy and was sitting on the edge of the bed. *The mattress continued to be: -In the same position as observed above. -Not secured in place by the metal brackets. Observation on 2/27/18 at 3:07 p.m. of resident 320 revealed: *He had been lying on his bed resting. *The mattress: -Continued to be not secured in place by the metal brackets. -Had shifted further to the left and moved down towards the foot of the bed. --That movement had exposed a larger portion of the bed frame. *The head of the mattress had moved down to expose approximately 3 inches of the bed frame. *The side of the mattress had shifted further to the left and exposed approximately 4 to 5 inches of the bed frame. Observation and interview on 2/28/18 at 9:45 a.m. with certified nursing assistant (CNA) D regarding resident 320's bed revealed: *The resident's bed had been made, and the fitted sheet had been placed over the metal brackets. *The mattress had been secured to the bed frame with the fitted sheet over those brackets. *CNA D: -Was not aware what the metal brackets were used for. -Had always made the resident's beds that way. -Could not remember being trained on the proper use for the metal brackets. -Confirmed the resident was independent in his room and had been able to transfer himself in/out of the bed. -Agreed the: --Position of the mattress as observed above was a safety concern for the resident. -Resident could have acquired a skin injury from the bed frame or fallen when transferring. Interview on 2/28/18 at 3:26 p.m. with the Minimum Data Set (MDS) assessment coordinator revealed she: *Agreed: -The mattresses should have been secured to the bed frames to ensure safety for the residents. -The observation above had created the potential for a skin injury or a fall for the resident. *Would not have always assessed the safety of the mattresses. *Relied upon the maintenance department to ensure the safety brackets were on the beds and used properly. *Was not sure if the maintenance department had put them on a preventative maintenance program for routine checking. *Had: -Checked those beds for the resident's who used positioning bars to ensure safe and appropriate use. -Not considered checking those beds and mattresses that did not use the repositioning bars for safety. Interview on 3/1/18 at 7:57 a.m. with the maintenance supervisor revealed: *He had not been aware of what the facility was using for bed frames, mattresses, and safety brackets in the TCU. *The only time he had checked the beds for proper placement of the mattresses was when he was asked to replace it with an air mattress. *He was not sure who should be checking to make sure the safety brackets were in place and had been used properly by the staff. *The maintenance department had not placed the safety brackets on a preventative maintenance program to routinely check for proper use and safety. *He agreed if they were not used properly any resident would have been at risk for injuries. Interview on 3/1/18 at 8:15 a.m. with registered nurse (RN) F and CNA J who worked on the TCU revealed: *They: -Had not been educated on the proper use for the safety brackets attached to the bed frames. -Agreed there was potential for any resident to have obtained an injury if the brackets were not used properly. Interview on 3/1/18 at 10:15 a.m. with the director of nursing (DON) and administrator revealed: *The DON was aware the mattresses in the TCU had not been the correct size for those bed frames. *The current bed frames and safety brackets had been ordered over a year ago when the TCU first opened. *The original mattresses that came with those beds and had concaved edges. *The maintenance department had reordered mattresses for those beds, and they came to small. *No one had ordered proper fitting mattresses for those beds to ensure safety of the residents. *The administrator had not been: -Aware of the above concern. -Sure who should have been responsible for the routine checking for the proper use of the safety brackets and security of the mattresses. Review of the provider's (MONTH) (YEAR) Zenith 5,000 Manufacturer's Instructions for use revealed: *The safety brackets, or retainers, could be positioned for an eighty inch or seventy-six inch mattress. *The the instructions on how to insert properly into the bed frame. *Important: -Be sure to use a mattress that is properly sized to fit the sleep deck, which will remain centered on the deck relative to State and Federal Guidelines. -Use of an improperly fitted mattress could result in injury or death.", "filedate": "2020-09-01"}
{"rowid": 98, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2018-03-01", "deficiency_tag": 919, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "2S8V11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure a consistent process was in place for a multi-use call light system to support the resident's needs had been met in a timely and efficient manner. Findings include: 1. Random observations on 2/27/18 from 8:00 a.m. through 9:50 a.m. in the Transitional Care Unit (TCU) revealed: *Most of the residents were out in the dining room eating their breakfast or exercising with the therapists. *The residents observed in the dining room wore a long necklace with a square pendant attached to it. -The center of the pendant contained a rubber type material. *The residents' rooms all had call lights located by their beds and in the bathrooms. *There were no lights above the residents' doors to notify the staff when a resident had turned on their call light. *There was a digital board located at the south end of the hall attached to the wall above the exit door. *The digital board: -Was approximately 20 feet from the dining room area and the nurses' station. -Made a loud beeping noise whenever a resident would push their call light for assistance. -Would only beep once for each call light. -Had large red digital numbers that would run across the board to indicate which resident's room had their call light on. -The room numbers on the board would keep running until staff answered the resident's call light. Interview on 2/27/18 at 8:53 a.m. with resident 320 revealed: *He had been in his room sitting on the bed. *His call light had been clipped to the cord and was hanging against the wall behind the bed's headboard. -That call light was not within his reach. *He had worn a pendant around his neck as observed on the other residents in the dining room. *He stated: -Its what I use for a call light. -I would rather use this than the regular call light. -We can use both, but I prefer to use this one. -I wear it all the time. Interview on 2/27/18 at 1:13 p.m. with CNAs D and [NAME] regarding the call light system revealed: *They confirmed most of the residents preferred to use the pendants on their necks versus (vs) the regular call light. *The staff wore pagers at all times to alert them of call lights that were on. -Those pagers would have revealed the resident's room number when they had put on their call light. *The digital board was another system in place for the staff to use to when checking the residents' call lights. *During the day shift: -Only the CNAs wore a pager. -The charge nurse would not have worn a pager to alert her when a resident put on their call light. *During the night shift there was only one CNA and the charge nurse. -Both the CNA and charge nurse wore the pagers during that shift. *They were not sure why the day shift charge nurse would not have worn a pager. *The CNAs pushed resident 321's pendant to demonstrate how they worked in conjunction with the pagers and the digital board. -The pagers made a vibrating noise, and the resident's room number appeared on it. -The digital board made a beeping noise and revealed the resident's room that needed assistance. *They had: -Demonstrated how to clear the resident's pendant. -To manually clear their pagers after they cleared the resident's pendant. Interview on 2/27/18 at 1:20 p.m. with licensed practical nurse (LPN) C regarding the call light system revealed: *She confirmed the interviews with CNAs D and E. *She did not know why the day shift charge nurses were not required to wear a pager. *She stated: - Its always been that way. -We don't even have another one down here. All we have are two pagers. *She confirmed the digital monitor: -Could not have been heard when she was down the hall or in another resident's room. -Would have only made one sound for each call light. *Unless she had heard the digital monitor or randomly checked it she had no way of knowing when a resident had their call light on and for how long. *She agreed that was not a safe process for the residents. Observation on 2/27/18 at 1:30 p.m. with CNA D and resident 320 revealed: *The CNA had the resident put his call light in his room. *The CNAs pager vibrated and his number appeared on her pager. *When he had put his call light on the digital monitor made a loud beeping noise, and his room number was shown on the monitor. -His room number had continued to show on the digital monitor until she cleared his call light. *The resident's room number continued to show on her pager until she manually cleared it. Interview on 3/1/18 at 9:13 a.m. with registered nurse (RN) F revealed she: *Had not been wearing a pager. *Confirmed the above interview with LPN C. Interview on 3/1/18 at 10:50 a.m. with the administrator and the DON regarding the call light system in the TCU revealed: *The administrator had not been aware: -The charge nurse was not wearing a pager during the day shift. -There were only two pagers for the staff to use in the TCU. -That had always been their process. *The DON: -Had been aware there were only two pagers for the staff to use in the TCU. -Stated: --I never wear one myself when I work down there during the day. --I check with the staff and the digital monitor to see if they need help. --I have never had any problems. -Agreed she could not guarantee all the day shift charge nurses would have checked with the staff or digital monitor to ensure there were no call lights that needed answering. *They would not comment on whether the day shift charge nurse should wear a pager to ensure: -The safety and well being for the residents. -The personal and care needs for the residents had been met in a timely manner. *The DON stated I don't like that call system. Its not very effective. The pager doesn't clear the room number off of it when you answer the call lights. You have to manually remove the number. 2. Random observations on 2/27/18 from 1:00 p.m. through 4:00 p.m. on the 200 wing revealed: *There were no lights above the resident's doors to notify the staff when a resident had pushed their call light. *There was a digital board located at the end of the hallway above the exit door. *The digital board: -Had large red digital numbers that would run across the board to indicate which resident's room had their call light on. -The room numbers on the board would keep running until the staff answered the resident's call light. Interview on 2/27/18 at 1:00 p.m. with registered nurse (RN) I regarding resident 43's use of her call light revealed: *She had a [DIAGNOSES REDACTED]. *She neededtotal assistance of two staff with a Hoyer lift for transfers. *She used a bed pan for her bladder and bowel needs. -She was watched closely when on the bed pan. -She had the potential for skin break down. *She had no use of her extremities. *She was able to move her head up and down. *She used a soft touch pendant for her call light. *She would depress the call light with her chin. *Staff would attach the call light to the bed sheet or her clothing. -That would prevent the call light from falling or slipping. *When her call light was pushed it would be: -Displayed on the digital board located at the end of the hallway. -The room numbers on the board would keep running until the staff answered the resident's call light. -Displayed on the computer screen at the nurses station located at the beginning of the hallway. Interview and observation on 2/27/18 at 1:50 p.m. with certified nursing assistant (CNA) R regarding the call lights on the 200 wing revealed: *That two CNAs were assigned to the 200 wing. *When a resident had their call light on the room number would be displayed on the: -Digital board located at the end of the wing above the exit sign. -The room numbers on the board would keep running until the staff answered the resident's call light. -Computer screen at the nurses station located at the beginning of the wing. *There had been no alarm or beeping system to alert them of a call light being on. *She stated Since we do not have an alarm system we look at the digital board and computer screen frequently. Interview on 2/27/18 at 2:05 p.m. with CNA S regarding call lights on the 200 wing revealed: *She was covering on the 200 wing for the CNA's break. *She was one of the CNAs assigned to the 400 wing. *When a resident put their call light on: -It showed up on the screen at the end of the hallway. *Staff had walkie-talkies to use if they needed assistance from other staff. Interview and observation on 02/27/18 at 4:00 p.m. with resident 43 regarding the call lights revealed: *She had a [DIAGNOSES REDACTED]. *She needed total assistance of two staff with a Hoyer lift for transfers. *She used a bed pan for her bladder and bowel needs. *She was checked on frequently when put on the bed pan. *She did not have use of her extremities. *She was able to move her head up and down. *She used a soft touch pendant for her call light. *She would depress the call light with her chin. *Staff would attach the call light to the bed sheet or her clothing. -That would prevent the call light from falling or slipping. Interview on 2/28/18 at 2:30 p.m. with CNA T regarding the call lights on the 200 wing revealed: *The digital board at the end of the hallway lite up when a call light was pressed. -It would display the resident's room number. *The resident's room number would be displayed on the computer screen at the nurses station. *To her knowledge that was the only way to know if the resident had put on their call light. *There was no alarm system alerting them of a call light being on. *Staff had walkie-talkies to use if they needed assistance from other staff. Interview on 2/28/18 at 2:40 p.m. with CNA R regarding the 200 wing call lights revealed: *The digital board at the end of the hallway light up when: -A resident pushed their call light and stays lite up until the resident's call light was turned on or turned off. *The resident's room number would be displayed across the computer screen at the nurses station. *She stated she checked the computer screen at the nurses station frequently. *To her knowledge that was the only way to know if the resident's puts on their call lights. *If she needed help then she had a walkie-talkie to radio for assistance. -She stated one CNA stayed on the hallway at all times. *To her knowledge that was the only call system available at the facility. 3. Observation and interview on 2/27/18 at 11:20 a.m. with resident 41 revealed: *She had been sitting in her recliner in her room with the TV on. *Her left leg was stuck in-between the recliner seat and the foot rest. *The gap between the two areas had been approximately four inches. *She could not put her call light on when asked to, and she just looked at it. *The surveyor put her call light on. *The resident grimaced when she attempted to move her leg. *No one had come to her room. -An unidentified activities staff member was doing an activity in the common area and was asked if there were staff around who could assist the resident. *She stated she was not sure and looked around the area. *She then pointed out a certified nursing assistant (CNA) on the south end of the common area. *The staff member was asked if she got a page for room [ROOM NUMBER]. *She stated she was not wearing a pager. *They used the banner at the end of the hall to see what call lights were going off. *There had been no alarm sounding in the hallway. *There was no light outside the door to indicate the call light had been activated. Interview on 2/27/18 at 1:00 p.m. with certified nursing assistant (CNA) L and CNA M in the 200 hall revealed: *CNA L had been employed for one year. *CNA M had been employed for one week. *CNA L did not have a pager on her person for the call light system. *CNA M did not have one and was waiting to get one. -She stated call lights were to be answered in seven minutes. -The use of the pager was optional. *They used the banner board at the end of the hall. *It was hard to read if one was at the opposite end of the hall. *The other option was to go behind the nurses station to read it off the computer. *A light ding sounded when the call light was pushed but did not stay on. -The ding could not be heard if you were in another resident's room with the door closed. *Currently 203B and 206B call lights were going across the board. -They were still on at 1:10 p.m. Resident council meeting on 2/27/18 at 2:25 p.m. with a group of residents and two family members revealed: *They had concerns with the call light wait times. *Staff would come in the room, turn off the call light, and say they would come back later. -They would not always come back. *The wait times got better for a little while but had gotten bad again. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: *She had been employed for one year and had a pager on her person. *She was asked to demonstrate how she knows what room was needing assistance. *She stated Bear with me as this is new to me. *She had only had the pager a few days. *They had not had enough pagers for everyone, and they would run out. *The other CNA on the 300 hall was currently on break. *There were only two CNAs on that hall. *When the other CNA went on break they would have to call over the walkie-talkies to get another CNA from a different hall to help them. Interview on 2/28/18 at 2:25 p.m. with the DON revealed: *It was not a requirement to carry pagers. *The pagers were old and did not work the best. *The room number would not clear off the pager unless it was manually reset on each individual pager. -The CNAs would not know if the resident had already been helped so they would have to take the time to go to the room and check. *Pagers are not the problem regarding the call light wait times. *She did not like the pagers. *They had not looked at pagers or staffing as being a problem with the call light wait times. Interview on 2/28/18 at 3:10 p.m. with the human resources director regarding the call light system revealed: *She was responsible for running the call light log reports. *The residents could choose to use a pendant call light. *If the resident was in the living room or open court area and pushed the pendant the staff would probably check the resident's room first. *There was no way to know where the resident was if they pushed the pendant. Interview on 3/01/18 at 3:13 p.m. with the DON revealed: *She was not sure if they had the correct pagers that went along with the call light system. *She had asked a CNA to bring over their pager to look at. *That pager the CNA was carrying was an Apollo AL-924L with a digital paging company label. *She again stated she did not like the pagers. Review of the Arial Wireless Communication Systems Installation Manual revealed: *The Arial system uses wireless transmitting devices to notify staff members of an incident within the facility. *If the paging system is being used, staff members carrying the pagers are automatically notified of the call, without having to return to the Arial CMS. *The pager model number was . *The paging option allows staff members to be notified of a potential emergency anywhere within the coverage area. *The pager informs staff of calls for help and when those calls have been cleared. Review of the provider's (MONTH) (YEAR) Answering the Call Light policy revealed: *Staff were to answer the resident's call light as soon as possible. *It had not addressed the use of the call light system and pagers.", "filedate": "2020-09-01"}
{"rowid": 99, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2019-05-23", "deficiency_tag": 550, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "LF7K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure three of six residents (52, 73, and 125) who required a full body sling with lift transfers were given an option to use a commode or toilet. Findings include: 1. Review of resident 52's medical record revealed:*An admission date of [DATE].*She had a Brief Interview for Mental Status (BIMS) score of two indicating she was severely cognitively impaired.*Her 4/16/19 quarterly Minimum Data Set assessment (MDS) revealed:-She was an extensive assist with a two plus person physical assist for:--Bed mobility.--Transfers.--Dressing.--Toilet use.--Personal hygiene.--Bathing.Interview on 5/21/19 at 8:06 a.m. after resident 52's brief change with certified nurse aides (CNAs) O and P revealed:*She was a Hoyer lift resident.*Residents that are a Hoyer lift and wear a brief are not brought into the bathroom.-It is to hard to get the Hoyer sling off of the resident so they could use the toilet or commode.*They stated residents urinate and have bowel movements (BM) in their brief.-Residents are then changed.*Residents can have a bedpan if they choose.*They are not given the choice to use the toilet.Interview on 5/22/19 at 1:18 p.m. with CNA M concerning resident 52 revealed:*If a resident is a Hoyer lift, their choice is to use a bedpan or urinate or have a BM in their brief.*We check her brief when we lay her down.*She won't use a bedpan.*She uses a Hoyer lift.*We do not toilet her.*I don't know what else we're suppose to do if she will not use a bedpan. She is a Hoyer lift. Interview on 5/22/19 at 1:34 p.m. during resident 52's brief change with CNAs H and N revealed:*They both state they check on her every two hours.*She urinates and has BM's in her brief.*She is a Hoyer lift.*There is no way to toilet her or put her on the commode.-They do not have the correct Hoyer sling to do that. 2. Review of resident 73's 3/29/19 MDS assessment revealed: *She had been admitted on [DATE]. *Her BIMS score had been thirteen indicating her cognition was intact. *She required the extensive assistance of one staff member for personal hygiene. *She was totally dependent on two or more staff members for: -Dressing. -Transfers. -Toilet use. -Bed mobility. *She had an indwelling catheter and had been frequently incontinent of bowel. Interview on 5/21/19 at 7:40 a.m. with resident 73 revealed: *She could not walk or stand and required a total lift for transfer. *She could not use the toilet for bowel elimination due to needing the total body lift. *She stated it would be too hard for the staff to get her into the bathroom and onto a toilet. *She did not know what a commode was and had never been offered one for bowel elimination. Interview on 5/21/19 at 8:00 a.m. with CNA Q revealed, residents who use a total body lift must use the bed pan. Interview on 5/21/19 at 9:23 a.m. with CNA A revealed, residents using a total lift had to use the bed pan due to not being able to access the toilet with the lifts. Interview on 5/21/19 at 9:26 a.m. with physical therapy assistant (PTA) B revealed: *He did the nursing assistant training for lift use. *Residents cannot be toileted with a total lift due the full body slings. Interview on 5/22/19 at 11:01 a.m. with unlicensed assistive personnel (UAP) C revealed, residents who required a total lift had to use the bed pan. Interview on 5/22/19 at 11:02 a.m. with UAP D revealed: *The provider did have mesh slings that would allow for toileting with a total lift. *She was not aware of this until a few days prior. -She was informed of these slings due to another resident who currently used the toilet being evaluated for a total lift. *There were no bathrooms big enough to get into with a resident in a total lift. Interview on 5/22/19 at 11:04 a.m. with CNA [NAME] revealed, she did not believe residents who required a total lift could use a toilet or commode. Interview of 5/22/19 at 2:10 p.m. with resident 73 revealed: *She was unable to get onto a bed pan and had to eliminate her bowels in her incontinent products. *When asked if she felt embarrassed about having to use her incontinent product for bowel elimination she stated, I have to go in my diaper and that is it. *She then changed the topic to her upcoming birthday party and the weather. 3. Review of resident 125's medical record revealed: *An admission date of [DATE]. *A BIMs of thirteen that indicated she had been cognitively intact. *Her admission MDS assessment revealed: -She required extensive assistance with two person physical assistance for: --Bed mobility. --Transfers. --Dressing. --Personal hygiene. --Bathing. -She had an indwelling urinary catheter. -She had been frequently incontinent of bowel. Interview on 5/22/19 at 11:02 a.m. with resident 125 revealed she: *Had to use the bedpan for bowel elimination. *Stated she: -Did not like using the bedpan. -It had been embarrassing for her to ask to use the bedpan. -Had been told by staff she had to use the bedpan for bowel elimination. Interview on 5/22/19 at 8:30 a.m. with CNA U revealed she stated: *Resident 125 used the bedpan for bowel movements. *That was how she had been told to assist her by the nurses and therapy. *She thought the resident could probably use a commode but could not do that unless therapy told them they could. Observation on 5/22/19 at 2:00 p.m. of resident 125 while she had been in the therapy room revealed: *She was sitting in a chair with her right leg extended and elevated on a therapy ball. *The certified occupation therapy assistant W and CNA U were looking for a commode. -It took fifteen minutes to find a commode. *That commode was to have been used to do a dry run transfer for the resident to use a commode for bowel elimination. Observation on 5/22/19 at 2:35 p.m. of resident 125 in her room revealed a stand aid transfer done by CNA U and PTA B. They assisted the resident onto the commode. The resident had a continent bowel movement. Interview on 5/23/19 at 9:45 a.m. with resident 125 in the therapy room revealed she stated It is a good thing I don't have to use that bedpan anymore. I could do it but really did not like it. It is much better now when I can use a commode. Easier too. Interview 5/23/19 at 10:45 a.m. with the DON confirmed resident 125 should not have had to use the bedpan for bowel elimination. She stated There are alternate ways. Review of providers Qtr 3, (YEAR) Quality of Life-Dignity policy revealed: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Treated with dignity meant the residents will be assisted in maintaining and enhancing his or her self-esteem and and self-worth. *Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to resident's request for toileting.", "filedate": "2020-09-01"}
{"rowid": 100, "facility_name": "ROLLING HILLS HEALTHCARE", "facility_id": 435035, "address": "2200 13TH AVE", "city": "BELLE FOURCHE", "state": "SD", "zip": 57717, "inspection_date": "2019-05-23", "deficiency_tag": 656, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LF7K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to develop and revise individual care plans to reflect the needs and desires for eight of nineteen sampled residents (9, 23, 45, 52, 53, 56, 62, and 73). Findings include: 1. Review of resident 56's care plan with a print date of 5/22/19 revealed: *A focus area for a pressure wound. *A new skin area concern on 5/21/19 had not been identified on the current care plan. Refer to F686 finding 4. 2. Review of resident 62's current care plan printed on 5/22/19 revealed: *A focus area for skin breakdown. *The interventions for the above areas had been I am refusing foam boots, staff will continue to offer these. offer pillows to offload heels when in bed. Refer to F686 finding 4. Resident #52 3. Review of resident 52's care plan revealed:*Focus:-I need assistance in:-Dressing. -Grooming. -Bathing.-Date initiated: 10/11/18.*Interventions:-I need extensive assist of one staff with my:-Dressing.-Grooming.-Bathing.-Date initiated:10/11/18. *Her 4/16/19 quarterly minimum data set revealed: -She was an extensive assist with a two plus person physical assist for: --Dressing. --Personal hygiene. --Bathing.*Focus:-Transfers/Bed Mobility/Ambulation.-Date initiated: 10/11/18.*Interventions:-Staff use a sit to stand lift to transfer me.-I need extensive assistance of one staff person with: --Bed Mobility.--Transfers.--Ambulation.-Date initiated: 10/11/18.*Focus: -I am at risk for falls. -Date initiated: 10/11/18.-Revision on 11/6/18. *Interventions: -Do not leave me unattended in my wheelchair in my room, as I may fall out of it. -Date initiated: 1/2/19.Interview on 05/23/19 at 12:30 p.m. with the DON concerning resident 52 revealed she agreed:*She was not to be left alone in a wheelchair in her room.*She was a Hoyer lift.*The careplan needed to be updated to match the Minimum Data Set and her needs.Refer to F550, finding 1 and F684, finding 1. 4. Resident 23 did not have a complete and comprehensive care plan. Refer to F745 finding 2. 5. Resident 9 did not have a complete and comprehensive care plan. Refer to F686 finding 1. 6. Resident 45 did not have a complete and comprehensive care plan. Please, refer to F686 finding 2. 7. Resident 73 did not have a complete and comprehensive care plan. Please, refer to F686 finding 3. 8. Review of resident 53's medical record revealed he had: *A [DIAGNOSES REDACTED]. *admitted on [DATE]. *A history of extended spectrum beta lactamase (ESBL). *A new pressure ulcer on his left calf which had been discovered on 3/11/19. Review of resident 53's 3/15/19 revised care plan revealed: *No documentation found on his care plan regarding the 3/11/19 pressure ulcer on his left calf until 4/29/19. *On 3/15/19 his contact precautions for ESBL had been discontinued. -Staff had continued to follow contact precaution practices after 3/15/19. -There was no physician order for [REDACTED].>Interview on 5/23/19 at 11:53 a.m. with the administrator and DON regarding resident 53's care plan: *Confirmed the care plan should have been revised. *Acknowledged the care plan had not been updated to reflect his current status. Review of the provider's dated Quarter 3, (YEAR) Care Plans, Comprehensive Person-Centered policy and procedure revealed: *A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. *Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.", "filedate": "2020-09-01"}