cms_SD: 52

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
52	MONUMENT HEALTH CUSTER CARE CENTER	435032	1065 MONTGOMERY ST	CUSTER	SD	57730	2018-09-13	610	D	0	1	YYKW11	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.	2020-09-01