cms_SD: 49

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

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

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
49	MONUMENT HEALTH CUSTER CARE CENTER	435032	1065 MONTGOMERY ST	CUSTER	SD	57730	2018-03-28	758	G	0	1	CZRE11	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.	2020-09-01