cms_SD: 40

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

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

This data as json, copyable

rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
40	MONUMENT HEALTH CUSTER CARE CENTER	435032	1065 MONTGOMERY ST	CUSTER	SD	57730	2018-03-28	609	E	1	1	CZRE11	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.	2020-09-01