cms_TN: 14274
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
14274 | KINDRED NURSING AND REHABILITATION -LOUDON | 445253 | 1520 GROVE ST BOX 190 | LOUDON | TN | 37774 | 2010-01-27 | 323 | D | S2CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were functional or in the lowest position for three (#6, #13, #14) of twenty-nine residents reviewed. The findings included: Resident #6 was admitted the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognitive skills, required extensive assistance with transfers/ambulation, and had fallen in the past ,[DATE] days. Medical record review of the current Care Plan reviewed on [DATE], revealed "...Resident is at risk for falls...alarms to bed/chair..." Observation on [DATE], at 9:00 a.m., revealed the resident lying on the bed with a pressure pad alarm in place, however, the alarm box was not activated. Observation and interview, on [DATE], at 9:15 a.m., with Licensed Practical Nurse (LPN) #1 revealed the resident lying on the bed, with a pressure pad alarm in place, and confirmed the alarm was not turned on/activated. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, and moderately impaired cognitive skills for daily decision making. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], revealed, " ...Pressure Alarm On When Resident in Bed... " Medical record review of the Care Plan dated [DATE], revealed, "...pp (pressure pad) alarm in bed..." Observation on [DATE], at 1:50 p.m., revealed the resident entered the bathroom and closed the door. Continued observation with RN #2 revealed a pressure pad alarm on the bed, but not sounding. Further observation of the pressure pad alarm revealed, " Six month thin bed sensor pad", dated [DATE], in black marker. Interview on [DATE], at 1:50 p.m., with RN #2, in the resident's room, confirmed the pressure pad alarm was not sounding, and the sensor pad had expired. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems with severely impaired cognitive skills for daily decision making. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the physician's recapitulation orders dated [DATE], through February 10, 2010, revealed, "...Low Bed with mat ..." Medical record review of the care plan dated [DATE], revealed, "...Low Bed..." Observation on [DATE], at 10:45 a.m., with LPN #4, revealed the resident lying in the bed. Observation revealed the bed was not in the low position. Interview at this time with LPN #4, in the resident's room, confirmed the bed was not in the low position. | 2014-02-01 |