cms_TN: 13916
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 13916 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2009-02-12 | 514 | D | 1 | 1 | XMN911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a medical record was complete for two (#14, #15) of thirty-two residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. intake. Interview on February 11, 2009, at 7:35 a.m., with Licensed Practical Nurse (LPN) #2, responsible for the resident's care, in the hallway, revealed the resident was on a 1500cc fluid restriction Interview on February 12, 2009, at 7:15 a.m., with the Registered Dietician, in the nursing station, revealed the dietary department provided 750cc of fluid daily, to the resident, with meals, and nursing provided an additional 750cc of fluid. Interview on February 12, 2009, at 7:30 a.m., with LPN #3, in the hallway, revealed dietary provides 740cc of fluids, the resident received approximately 240cc of water with the morning medications, and the Certified Nursing Assistants (CNA) notified LPN #3 of the resident's fluid intake daily. Interview with CNA #1 on February 12, 2009, at 7:35 a.m., (CNA responsible for the resident's care), in the hallway revealed an awareness of the resident's fluid restriction. Continued interview revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 12, 2009, at 7:40 a.m., with CNA #2, in the hallway, revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 11, 2009, at 8:00 a.m., with the Director of Nursing, in the conference room, confirmed there was no documentation of the amount of the resident's daily fluid intake. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had modified independence with daily decision making, and required assist of one person for transfers and ambulation. Review of the nurse's notes dated March 31, and April 1, 2008, revealed the resident had fallen on Easter Sunday (March 23, 2008). Review of the facility's investigation dated April 4, 2008, revealed, "Pt. found on floor at bed...no apparent injury. Nurse never notified anyone..." Review of the nurse's notes dated March 21st through March 30th, 2008, revealed no documentation the resident had fallen. Review of the facility's policy, Protocol for Falls, revealed, "After a fall staff will: ...3. Notify family and MD (Medical Doctor); 4. Place on alert charting for 72 hours;...6. Print out Post Fall Assessment; 7. Start in depth investigation, after printing Post Fall Investigation; 8. Notify staff of changes in Patient Care Plan by oral report, written intervention on assignment sheet..." Observation on February 10, 2009, at 3:00 p.m., in the resident's room, revealed the resident seated in a wheelchair at the bedside. Resident was alert, oriented, able to recall events of childhood and family history. Interview with the resident at this time revealed the resident recalled, "...had been up to bathroom, fell and broke hip..." Interview with the Director of Nurses on February 11, 2009, at 1:30 p.m., in the Director's office, confirmed no documentation had been made in the clinical record at the time of the resident's fall. | 2014-07-01 |