cms_SD: 83

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
83	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2017-02-01	323	D	0	1	X0TZ11	Based on observation, record review, interview, and policy review, the provider failed to complete fall risk assessments, implement interventions, and complete thorough fall investigations for one of one sampled resident (3) who had multiple falls. Findings include: 1. Observation on 1/31/17 at 9:10 a.m. of resident 3 revealed she had been: In her room sitting half-way off the seat of her wheelchair. Confused when talking to the medication aide. Scooting around in her room in her wheelchair with her feet. Attempting to pick clothes up off the recliner and was leaning forward. Review of resident 3's medical record revealed she had fallen on 1/28/16, 1/29/16, 2/1/16, 3/8/16, 6/3/16, 7/4/16, 10/5/16, 10/7/16, 10/8/16, 10/18/16, 11/2/16, 11/26/16, 12/18/16, and 1/17/17. Review of resident 3's 8/24/16 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was a three. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 11/24/16 MDS assessment revealed her BIMS score was a one. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 5/16/16 Fall Risk assessment revealed: She had a score of fourteen. -A score of ten or above indicated a risk for falling. There had not been an (MONTH) (YEAR) or (MONTH) (YEAR) Fall Risk assessment completed. Review of resident 3's 10/5/16 Fall Scene Investigation report revealed: She had lost her balance while reaching for a piece of paper on the floor. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time?) section had not been completed. There had been no change to the current care plan. Review of resident 3's 10/7/16 Fall Scene Investigation report revealed: She had lost her balance while reaching for a piece of paper on the floor. The medications given in last 8 hours section had not been completed. The re-creation of last 3 hours before fall section had not been completed. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time) section had not been completed. The root cause of the fall section had not been completed. There had been no change to the current care plan. Refer to therapy to screen was written under conclusion. Review of resident 3's 10/8/16 Fall Scene Investigation report revealed: She had been walking into room and legs appeared to go out. The last time toileted section had not been completed. The medications given in last 8 hours section had not been completed. The re-creation of last 3 hours before fall section had not been completed. The fall huddle (What was different this time) section had not been completed. The root cause of the fall section had not been completed. There had been no change to the current care plan. An initial intervention had been Have a separate staff member in day room or activity room keeping a close eye on our high risk individuals. Refer to therapy to screen was written under conclusion. Review of resident 3's 10/18/16 Fall Scene Investigation report revealed: She had been found sitting on the floor in her room. The medications given in last 8 hours section had not been completed. The re-creation of last 3 hours before fall section had not been completed. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time) section had not been completed. The root cause of the fall section had not been completed. There had been no change to the current care plan. There had been no initial interventions documented. Continue to encourage her to call for help was written under conclusion. Review of resident 3's 11/2/16 Fall Scene Investigation report revealed: She had been found sitting on the floor in the bathroom. The last time toileted section had not been completed. The medications given in last 8 hours section had not been completed. The re-creation of last 3 hours before fall section had not been completed. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time) section had not been completed. The root cause of the fall section had not been completed. There had been no change to the current care plan. There had been no initial interventions documented. Staff to check on often was written under conclusion. Review of resident 3's 11/26/16 Fall Scene Investigation report revealed: She had slipped out of the wheelchair. The last time toileted section had not been completed. The re-creation of last 3 hours before fall section had not been completed. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time) section had not been completed. The root cause of the fall section had not been completed. There had been no change to the current care plan. There had been no initial interventions documented. Review of resident 3's 12/18/16 Fall Scene Investigation report revealed: She had been found sitting on the floor in her room. The re-enactment of the fall section had not been completed. The fall huddle (What was different this time) section had not been completed. There had been no change to the current care plan. The initial intervention was Monitor resident closely, anticipate needs. Resident should not be left in room alone when awake and alert. Take to open court in day room until ready to sleep. Under conclusion Activities notified to try to include her in activities. Review of resident 3's 1/17/17 Fall Scene Investigation report revealed: She had slid out of her recliner. There had been no change to the current care plan. Under initial interventions Instructed resident on use of controls and to use call light if assistance is needed. Review of resident 3's current undated care plan revealed: She had a focus area for falls. The interventions had been: -Ensure my call light and/or pendant is within reach. Keep my room and hallway free from clutter initiated on 10/5/14 and revised on 7/25/16. -I am using a w/c (wheelchair) so I can propel myself around the facility independently initiated on 11/16/16. -I am working with restorative therapy to help improve my strength and abilities initiated on 10/5/14 and revised on 10/16/15. -I will need staff to check on me frequently related to my confused state to see if I have any needs. I do not always remember to use my call light. I have a pendant alarm, but do not always remember to carry it with me. I do often take my pendant off so monitor for this and put it back on as needed. I have poor safely awareness and am not able to anticipate hazardous situations initiated 10/5/14 and revised on 12/19/16. -Keep my lamp on at night initiated 11/9/15. -Self locking brakes to my w/c. I often transfer myself despite being educated to not transfer self and to call for assist. Check on me frequently. I also often shut my door when I am in my room, monitor for this and open it up. Also encourage me to stay in open court, activity room or day room so my whereabouts can be monitored more closely initiated on 12/19/16. Review of resident 3's discontinued care plan revealed the discontinued interventions for the fall focus area were: Cup holder placed on walker to prevent tipping of cup. Will place cup holder on walker. Keep my walker within reach at all times. There had been no other interventions listed on that care plan under the focus area for falls. Interview on 2/1/17 at 8:50 a.m. with the restorative aide revealed resident 3 was scheduled for restorative therapy three times per week. Her scheduled days were Monday, Tuesday, and Wednesday. She mostly attended the group activity that worked on the upper extremities. She had the Nu-Step listed as PRN (as needed). She would offer the Nu-Step to the resident if she refused to attend the group restorative activity. The resident seemed to like the Nu-Step. She was the only restorative aide for forty-five residents. Interview on 2/1/17 at 2:30 p.m. with the director of nursing, the administrator, and the nurse consultant regarding resident 3 and the above fall history revealed: They had no documentation she had seen therapy for a screening as part of the intervention from the 10/7/16 and 10/8/16 falls. There was no documentation they had been monitoring the resident more closely. They agreed a resident with a BIMS of one might not remember to use the call light. They had disabled the control on the recliner in her room after the incident on 1/17/17. -They agreed that could have been done before as an environmental intervention. The fall scene investigation reports had not been complete. They had not completed the fall risk assessments quarterly as they should have been done. Review of the provider's (MONTH) (YEAR) Fall Prevention policy revealed: A fall risk assessment should have been completed upon admission, quarterly, prior to the annual MDS, and with a change in condition. Fall precautions were to be reviewed and implemented after a fall occurred and as needed. The care plan was to be updated with any new and decided upon interventions. -That was to continue for three weeks post-fall or until the resident had not had further falls for thirty days.	2020-09-01