cms_SD: 93

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
93	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2018-03-01	689	G	0	1	2S8V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to have adequate supervision and interventions in place for one of one sampled resident (41) with multiple falls occurring in the facility and resulting in two major injuries. Findings include: 1. Review of resident 41's medical record revealed: She had been admitted on [DATE]. She had been admitted for weakness from the hospital. She had been at home prior to that with a care giver. She had been identified at risk for falls during her admission assessment. The 12/19/17 fall risk assessment score was twenty-one. -A score of ten or above indicated a risk of falling. -They were to implement the fall prevention protocol and place approaches in the plan of care. --The fall prevention protocol initiated had been: Resident is very confused. She was orientated to call light but does not appear to know how to use this. She will be working with therapy. Will initiate low bed/mat. She had twenty-four falls since her admission on 12/19/17. -Two of those falls had resulted in major injury, a [MEDICAL CONDITION] on 1/14/18 and a head injury on 2/22/18. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed: Her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. She had verbal behaviors that had occurred one-to-three days during the assessment period. She had not rejected care during the assessment period. She required assistance of one staff member for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Locomotion off the unit. -Toilet use. -Dressing. -Personal hygiene. Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -Diabetes. -[MEDICAL CONDITION]. She had a fall prior to admission. She had one fall with no injury since admission. Review of resident 41's 1/26/18 MDS assessment revealed: Her BIMS score was zero indicating she had severe cognitive impairment. She had no behaviors. She had rejected care one-to-three days during the assessment period. She required extensive assistance of two staff members for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Toilet use. She required assistance of one staff member for the following: -Locomotion off the unit. -Dressing. -Personal hygiene. Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -[MEDICAL CONDITIONS]. -Diabetes. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. They had documented no falls since admission or prior assessment. Review of resident 41's fall scene investigation reports from 12/19/17 through 2/28/18 revealed she had eight unwitnessed falls. Refer to F610, finding 1. Review of resident 41's fall scene investigation reports revealed the following witnessed falls: On 12/29/17 she had a witnessed fall at 2:30 p.m. that stated resident lost balance. -She had been alone and unattended. -The last time toileted had a question mark in the box. -Conclusion had been Is working with therapy cont (continue) with hourly checks. Ensure call light is within reach. -There had been no additional care plan updates documented. On 12/31/17 she had a fall in the open court area at 9:30 a.m. -She had been sitting in her wheelchair. -She stated her butt keeps sliding to edge of wheelchair. -Root cause: Cushion in wheelchair slick. Resident keeps sliding to edge of wheelchair seat. -Initial interventions to prevent future falls had been Staff to monitor positioning. -Additional care plan updates had been Ensure cushion has cover and is hooked to wheelchair. Therapy looking to adjust w/c (wheelchair). Review of resident 41's interdisciplinary notes from 12/19/17 through 2/27/18 revealed: She had also fallen on the following dates: -1/2/18. -1/3/18 a third time. -1/4/18. -1/5/18 two times. -1/6/17. -1/27/18. -1/28/18. -2/1/18. -2/2/18 two times. -2/5/18. -2/6/18. -2/7/18. There had been no fall scene investigation reports for the above falls. Review of resident 41's current undated care plan revealed: There had been no intervention to check on her hourly per the above 1/10/18 intervention. Her toileting plan had been to toilet every two hours. There had been no interventions regarding an individualized toileting plan. Interventions in place were initiated after the falls had occurred and not prior. Observation and interview on 2/27/18 at 11:20 a.m. of resident 41 revealed: She had been sitting in her recliner in her room with the TV on. She had a green/yellow bruise under her right eye and a two-inch bandage on her forehead. Her left leg was stuck in-between the recliner seat and the foot rest. The gap between the two areas had been approximately four inches. She asked to have her slipper put on. -She seemed unaware her leg was stuck. She was told her leg needed to be unstuck from the chair. She stated Oh no can you put on my slipper. She attempted to pull her leg out from between the gap but was not successful. She could not put her call light on when asked to, and she just looked at it. -The surveyor put her call light on. The resident grimaced when she attempted to move her leg. No one had come to her room. -An unidentified activities staff member was doing an activity in the common area and was asked if there were staff around who could assist the resident. She stated she was not sure and looked around the area. She then pointed out a certified nursing assistant (CNA) on the south end of the common area. The staff member was asked if she had gotten a page for room [ROOM NUMBER]. She stated she was not wearing a pager. She came to assist resident 41, and when she saw the residents leg stuck stated Oh wow! She then used her walkie talkie to call another CNA as her partner on that hall had been on break. -The CNA she called stated she would be down after she helped another resident. The CNA in resident 41's room assisted the resident by herself and pulled her leg out of the gap. She then left the room. Observation and interview on 2/27/18 at 11:45 a.m. with registered nurse (RN) I regarding resident 41 revealed: The resident was lying in her bed. RN I stated she was told about the resident getting her leg stuck in the recliner. They were going to remove the recliner from her room due to the incident. At that time the maintenance director came over to take the recliner out of her room. RN I stated the resident can not be left alone in her wheelchair without supervision, as she had fallen out of the wheelchair. -She had hit her head as a result of falling out of her wheelchair. Observation on 2/27/18 at 12:30 p.m. of resident 41 in the dining room revealed: She had been pushed up to the table. Her foot pedals had been angled up. She had not been able to get up to the table due to the foot pedals being angled up. The foot pedals hit the tablemate to her right when she was pushed closer to the table. Interview on 2/27/18 at 12:40 p.m. with CNA P revealed: They had tried to put the foot pedals down in her w/c, but she was not sure why they left them up. She went over and took the pedals off and pushed her closer to the table. Recreation services aide Q stated she had not known the foot pedals were to come off. Observation on 2/27/18 at 2:10 p.m. and again at 4:50 p.m. of resident 41 revealed she was lying in bed. The recliner had been taken out of her room and not replaced. Observation on 2/27/18 at 6:25 p.m. of resident 41 revealed: She had been lying in bed. She was attempting to get out of bed. Both her legs were over the scooped mattress. She was trying to lift her body up to get out of bed. She was wide awake. There were no CNAs in the area. -The director of nursing (DON) was found and the above situation was explained to her. Observation on 2/28/18 at 7:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. There were no staff in the common area. Observation on 2/28/18 at 8:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. She was slouched over. The leg pedals were angled up. Observation on 2/28/18 at 8:49 a.m. regarding resident 41 revealed: She was slouched over in her wheelchair sleeping. There had been no staff in the area supervising her. The leg pedals were angled up. Observation on 2/28/18 at 9:02 a.m. of resident 41 revealed she was taken into her room and laid down. Observation on 2/28/18 at 9:27 a.m. of resident 41 revealed she was attempting to get up out of bed. There had been no staff around to witness her attempt at getting up. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: They checked on resident 41 every two hours to see if she needed to go to the bathroom. They usually laid her down in between meals. She is the first one they lay down after breakfast, and the last one to get up before lunch. She had been the only CNA on the 300 hall at that time due to her partner being on break. Observation on 2/28/18 at 10:00 a.m. of resident 41 revealed RN I had been in her room changing her dressings to her heels. She was in a sitting position with her feet hanging over the bed. She was lying back against wall. Observation on 3/01/18 at 9:59 a.m. of resident 41 revealed she was lying in bed with both feet hanging off the bed and heel protectors on. There were no staff around to observe her. Observation on 3/01/18 at 10:41 a.m. of resident 41 revealed she had been lying in bed. Both legs were hanging off the side of the bed. The lights were off. She was awake. Interview on 3/01/18 at 2:03 p.m. with the DON regarding resident 41 revealed: They were putting her in bed between meals, because she had to be supervised if she was up in her chair. They had not attempted an individualized bathrooming schedule for her. The CNAs only documented one time per shift that they toileted the resident. The fall interventions had been implemented after falls had occurred and not before for her. Review of the provider's (MONTH) (YEAR) Fall Prevention policy revealed: A fall risk assessment will be completed at the following times: -Upon admission/readmission to the facility. -Quarterly - can complete a quarterly review instead of full assessment if no change since previous assessment. -Prior to the annual MDS. -Change of condition. Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs and as needed. Incident report and a fall scene investigation form will be completed after fall. Falls will automatically be logged through completion of Incident Report in PCC (point click care).	2020-09-01