cms_SD: 6
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
6 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 610 | D | 0 | 1 | 9U2F11 | **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. | 2020-09-01 |