cms_SD: 1868

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
1868	AVANTARA ARROWHEAD	435051	2500 ARROWHEAD DR	RAPID CITY	SD	57702	2016-08-24	281	I	1	0	0LG211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure: Weekly skin reviews and wound documentation had occurred for 7 of 7 sampled residents (2, 4, 5, 8, 13, 14, and 18). Physicians' orders were in place for wound treatment for 1 of 6 sampled residents (14). The correct wound treatment had been completed by 1 of 1 licensed practical nurse (LPN) (D) on 1 of 4 sampled residents (13) who required a daily dressing change for a pressure ulcer. Physician's order to hold a medication was in the medical record for 2 of 21 sampled residents (2 and 7). Findings include: 1a. Review of resident 13's medical record revealed: He had been admitted on [DATE]. [DIAGNOSES REDACTED]. He had good memory recall. His blood pressure medication had been discontinued on 8/9/16. His blood pressure was to have been checked every day. He had been admitted with multiple wounds. Those wounds had been: -A surgical wound to his left knee. -A stage II pressure ulcer to his coccyx. -A stage II pressure ulcer to his right buttock. -An unstageable pressure ulcer to his right heel. He had been dependent upon the staff to assist him with activities of daily living (ADL). Incomplete wound documentation. A 7/29/16 physician's order for his skin to be assessed weekly. Review of resident 13's weekly skin review sheets from 7/22/16 through 8/10/16 revealed no documentation to support his skin had been assessed after 8/10/16. Those assessments had not been signed or dated by the licensed nurse. Review of resident 13's weekly wound evaluation flow sheets revealed: On 7/28/16: -The wound on his coccyx had been assessed. -No other wounds had been assessed. No documentation to support his wounds had been assessed for improvement, worsening, and healing after 7/28/16. No date or signature from the licensed nurse who had completed the assessment on 7/28/16. Review for resident 13's nurses' progress notes from 7/22/16 through 8/23/16 revealed no documentation to support complete wound assessments had been done on all of his wounds after 7/22/16. b. Review of resident 14's medical record revealed: She had been readmitted on [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. She had: -No muscle control and required assistance from the staff for positioning and transfers. -Required the use of a transfer aide to assist her with transfers in and out of the bed. -The staff assisted her out of bed once or twice a week per her choice. -Wounds to her sacral area. An 8/18/16 physician's order to assess her skin every week on Wednesday. Review of resident 14's 7/5/16 admission skin condition assessment revealed: Skin concern Tiny open spot on right buttock. No documentation to support the type of wound, size, and description of the wound to her right buttock. Review of resident 14's weekly skin review sheets from 7/5/16 through 7/25/16 revealed: The description and documentation of the wound to her right buttock had been conflicting. On: -7/5/16 and 7/13/16, a small open area to her right buttock. -7/18/16 and 7/24/16, moisture to right buttock. -7/25/16, she had a skin tear to her sacral area. No documentation weekly skin assessments had been completed after 7/25/16. No date or signature from the licensed nurse who had completed the weekly skin sheets. Review of resident 14's weekly wound evaluation flow sheets 7/5/16 through 8/23/16 revealed on 8/16/16: Site Coccyx. Type Skin tear. Stage Unstageable. Additional descriptions Received skin tear when being transferred to gurney by EMS personal (personnel). -Additional comments Wound is not open, has red edges, turning to white and has a dark center, suspecting deep tissue injury at this time. Patient is on a turn schedule but will refuse to reposition. No documentation wound had been assessed prior to and after 8/16/16. That wound assessment had not been signed or dated by the licensed nurse. Review of resident 14's nurses' progress notes from 7/5/16 through 8/23/16 revealed no documentation a complete wound assessment had been done after her admission on 7/5/16. c. Review of resident 4's medical record revealed an 8/17/16 signed physician's order: -Wound care to the right foot daily on the evening shift and as needed (PRN). --That physician's order had been initiated 6/27/16. -Weekly skin assessments every Thursday. -Weekly skin reviews. The provider was unable to produce from the electronic medical record any weekly skin assessments for resident 4. Review of nurses progress notes from 6/23/16 through 8/22/16 revealed three progress notes about the wound dressing change on the right foot. There was no documentation to determine a complete wound assessment had been done. Review of the (MONTH) and (MONTH) (YEAR) Weekly Skin Reviews completed for resident 4 revealed: 7/7/16: He had a bruise on the abdomen from insulin injections and pre-existing open area on right toes with scab and dry red areas. 7/14/16: He had a bruise and open area. Under other it stated he had a PICC (special intravenous device) line in his left arm, amputated toes, multiple bruises on abdomen. 7/21/16: He had pre-existing dry skin and pre-existing open area on the right toes; healing wounds due to post amputation of toes. 8/4/16: He had bruises from insulin shots on both upper arms and on his abdomen. He had a pre-existing open area right toes (amputation of toes before admission). 8/5/16: His skin was intact. No further weekly skin reviews were found. d. Review of resident 18's medical record revealed an admission date of [DATE] with a 7/21/16 signed physician's orders stating: -Weekly skin reviews every Thursday. -Those signed physician's orders did not include the admission order for : --Wound care to her LLE (left lower extremity). --Wound care to her right buttock. Review of resident 18's 7/15/16 admission nursing assessment of the skin conditions revealed: -No indication of where the wounds were on the pictures of the body. -A skin concern was documented for the LLL (left lower leg). An open area was observed on 7/15/16. --It did not indicate the stage of the wound or how the surrounding tissue appeared. --It was 4 cm (centimeters) by 2.5 cm but did not indicate how deep the wound was. -- It stated open area R/T (related to) [MEDICAL CONDITION] (skin infection); small amt (amount) of yellow drainage noted. -No other skin concerns were noted. Review of the resident 18's (MONTH) and (MONTH) (YEAR) Weekly Skin Review documentation revealed: 7/15/16: Open area r/t [MEDICAL CONDITION] to left lower leg (lateral side) approx. 4cm L X 2.5 cm W. Small amount of yellow drainage noted. Cleansed with normal saline applied [MEDICATION NAME]. 7/21/16: Her skin was dry with pre-existing redness and a pre-existing open area. -The open area was left lower leg stating wound from fall that occurred before admission. 8/4/16: An open area that was pre-existing on the outer aspect of LLE due to [MEDICAL CONDITION]. And the sacrum-open area due to sheer and moisture, barrier cream applied. 8/8/16: An open area on right thigh front. A skin tear measuring 4 inches by 0.5 inches. Review of the resident 18's Wound Evaluation Flow Sheet revealed: A pressure ulcer on the coccyx measured 0.1 X 0.1 X 0.1 cm, a stage two, red wound bed was identified on 7/15/16 upon admission. There was a pain management plan in place for the wound. There were preventative measures in place of a pressure redistribution mattress and a turn/reposition schedule. The care plan had been reviewed. That wound document was not signed or dated by the licensed nurse. There was no other wound documentation. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed she would have expected the weekly skin assessments to have included the wound length, width, depth, drainage, stage, surrounding tissue, and tunneling. The weekly skin reviews were to have been completed with baths to monitor for potential skin issues. Surveyor: 6. Review of resident 14's 8/8/16 nurse's progress note revealed New orders for daily dressing changes with hydrogel please see TAR (treatment administration record). Review of resident 14's physician's orders revealed no documentation an order had been noted by the licensed nurse who received the above treatment order change from the physician. 7. Review of resident 2's 8/23/16 nurse's progress note revealed: Updated PCP (primary care provider) re: wound care today and residents wishes. PCP gives order to hold collagen powder for 2 days and then to restart. Review of resident 2's (MONTH) (YEAR) TAR revealed: She was to have collagen powder applied to her open wounds on her buttocks daily. On 8/24/16 and 8/25/16 the above treatment to her wounds was to have been held. Review of resident 2's physicians' orders revealed no documentation to support an order had been noted by the licensed nurse who received the above treatment order change from the PCP. Interview on 8/24/16 at 9:20 a.m. with the field services clinical director confirmed she would have expected a physician's order to have been noted for the above wound treatment changes. 8. Observation on 8/23/16 at 3:15 p.m. of LPN D with resident 13 revealed: The nurse had: -Prepared to complete a dressing change to the resident's right heel. -Applied [MEDICATION NAME] to his right heel wound. Review of resident 13's medical record revealed: He had been admitted on [DATE]. He had been admitted with an unstageable pressure ulcer to his right heel. -The wound was to have been treated daily with [MEDICATION NAME]. On 8/16/16 the physician had changed the treatment to his right heel. -The [MEDICATION NAME] had been discontinued and Santyl ointment was to have been applied to the wound. The licensed nurse had not been available for interview regarding the above observation. Interview on 8/24/16 at 9:25 a.m. with the field services clinical director confirmed the treatment orders for resident 13 had changed on 8/16/16. She would have expected the licensed nurse to have followed the current physician's order of Santyl ointment. e. Review of resident 5's physician's orders revealed a weekly skin assessment was to have been completed. That order had been initiated on 1/10/16 and discontinued on 7/28/16. She had been admitted [DATE] with a stage 4 pressure ulcer. Surgery had been performed on 4/14/16 to close that wound. She was at high risk for redevelopment of a pressure ulcer. Review of her weekly skin assessments from 3/3/16 through 8/23/16 revealed documented assessments had been completed on: March: 3/30/16. April: 4/13/16. May: 5/16/16, 5/18/16. June: 6/15/16, 6/22/16, 6/29/16. July: 7/20/16. August: 8/3/16, 8/10/16. Those skin assessments had not been completed weekly as ordered by the physician. Review of her weekly wound documentation from 3/3/16 through 8/23/16 revealed it had been completed: 3/10/16. 3/23/16. After that time no further wound documentation was found in her record. Interview on 8/24/16 at 9:10 a.m. with the field services clinical director and the Minimum Data Set (MDS) coordinator revealed their expectation was weekly skin reviews should have been documented per physician's orders until it had been discontinued on 7/28/16. Wound documentation should have been maintained and completed until the wound had healed completely. Both confirmed a surgical incision and repair would have been considered a wound and appropriate assessment and documentation should have occurred. 10. Review resident 7's April, May, June, July, and (MONTH) (YEAR) medication administration records (MAR) revealed: A physician's order for Xtandi Capsule 160 mg by mouth one time a day. -April MAR indicated [REDACTED]. -May MAR indicated [REDACTED]. -June MAR indicated [REDACTED]. -July MAR indicated [REDACTED]. Review of the medical record revealed no physician's order to hold the medication for resident 7. Interview on 8/23/16 at 3:15 p.m. with the administrator preceptor confirmed there was no physician's order to hold the medication. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed the expectation would have been to have a physician's order to hold the medication and to document the physician's order. She stated the provider was ordering a Lippincott Manual as the professional reference for nurses. 11. Review of resident 8's complete medical record revealed: He was admitted on [DATE]. He had a stage 2 pressure ulcer on his coccyx. A 6/30/16 physician's order for a weekly skin review. A wound care assessment sheet had not been initiated upon admit. Weekly skin assessments had not been completed during that time. He had two weekly skin assessments during his stay. On 7/11/16 there was an incomplete weekly skin review with only: -Open area to coccyx. -No measurement of the area. Refer to 314, finding 4. 12. Review of resident 2's complete medical record revealed: She was admitted on [DATE] with four pressure ulcers. On 1/16/16 a skin tear had been identified. On 6/19/16 she acquired a pressure ulcer on her left lower hip area. Her wound evaluation flow sheets and weekly skin assessments were incomplete or had not been completed from admit through 8/18/16. Her care plan had not been updated: -When she had changes in her skin condition. -To reflect her current skin integrity. -From that incomplete documentation there was know way to know the current status of her wounds. Refer to F314, finding 5.	2019-08-01