cms_TN: 4843
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
4843 | NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C | 445373 | 202 EAST MTCS ROAD | MURFREESBORO | TN | 37130 | 2016-07-26 | 514 | D | 1 | 0 | AK2Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to have neurological assessments readily accessible for review during the survey for 1 (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the facility policy Neurological Assessment, dated 9/2014, revealed .Falls that occur and a patient hits their head or if the fall is unobserved and the possibility is there that a patient may have hit their head, a neurological assessment must be conducted to evaluate for possible impairment . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Monthly Falls Tracking Form, the facility documentation of the event and/or the investigation, and review of the medical record of the physician orders and progress notes revealed Resident #3 had the following: 1.) On 1/6/16 at 7:30 AM had an unobserved fall, was an unassisted self transfer from the wheelchair and was found on the floor next to the wheel chair. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/6/16 revealed an order for [REDACTED]. 2.) On 1/15/16 at 9:00 AM had an unobserved fall, was found lying on the floor mat next to the resident's bed. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/15/16 revealed an order for [REDACTED]. 3.) On 1/29/16 at 7:00 AM had a witnessed fall from the wheelchair to the floor hitting her head. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 2/1/16 revealed an order for [REDACTED].F/U (follow-up) fall/laceration Fore head/ .neurochecks 4.) On 6/6/16 at 1:15 AM had an unwitnessed fall from the wheelchair to the floor. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 6/7/16 revealed an order for [REDACTED]. Medical record review revealed no documentation presented to the surveyors during the survey, of neuro checks for the falls on 1/6/16, 1/15/16, 1/29/16 and 6/6/16 . Interview with the Director of Nursing (DON) on 7/20/16 at 10:05 AM in the DON's office, when asked if the neuro check documentation was available stated .No, I didn't find documentation . per facility policy. Interview with the Assistant Director of Nursing on 7/20/16 at 10:35 AM in the conference room confirmed the facility failed to have documentation of neuro checks, after the falls of 1/6/16, 1/15/16, 1/29/16 and 6/6/16, accessible for review during the survey. | 2019-07-01 |