cms_TN: 9055

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.

Data source: Big Local News · About: big-local-datasette

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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
9055	MT PLEASANT HEALTHCARE AND REHABILITATION	445374	904 HIDDEN ACRES DR	MOUNT PLEASANT	TN	38474	2013-07-10	278	D	0	1	098D11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual, medical record review and interview, it was determined the facility failed to accurately assess a resident for falls, vision, [MEDICAL TREATMENT] or terminal prognosis for 4 of 20 (Residents #19, 36, 47 and 66) sampled residents of the 33 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of incident reports documented Resident #19 fell [DATE], 4/15/13 and 6/6/13 with no injuries. Review of the fall risk assessment dated [DATE] and 4/15/13 documented, .HISTORY OF FALLS (Past 3 months) . 2 (indicating 1 to 2 falls in past 3 months) . Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 6/15/13 in section J1800 was coded as a 0, indicating no falls since prior assessment. During an interview in the conference room on 7/10/13 at 8:30 AM, the MDS Coordinator was asked if the falls in March, April and June 2013 were documented on the quarterly MDS dated [DATE]. The MDS Coordinator confirmed that it was not documented and stated, I don't know . 2. Review of the CMS's RAI Version 3.0 Manual documented, .B1000: Vision . Steps for Assessment . Test the accuracy of your findings . Ensure that the resident's customary visual appliance for close vision is in place (e.g. (example), eyeglasses, magnifying glass) . Medical record review for Resident #36 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment with an assessment reference date of 4/18/13 in section B1000 was coded as a 2, indicating moderately impaired - limited vision and B1200 was coded as a 0, indicating no corrective lenses used. During an interview in Resident #36's room on 7/8/13 at 3:30 PM, Resident #36 stated she uses the magnifying glasses to read. During an interview in the Social Worker's office on 7/9/13 at 5:25 PM, the Social Worker was asked why the MDS was marked no corrective lenses. The Social Worker stated, .didn't use it in the interview . I don't always have them (residents) use the corrective lenses in the interview . During an interview in the MDS office on 7/10/13 at 8:56 AM, the MDS Coordinator was asked if the RAI manual gives any guidelines on using corrective lenses or the magnifying glass during the assessment. The MDS Coordinator stated, Yes, use customary . 3. Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICAL TREATMENT] 3X (times) /WK (week) ON TUES (Tuesday), THURS (Thursday) & (and) SAT (Saturday) . Review of the 60 day MDS assessment with an assessment reference date of 6/27/13 in section O0100 J revealed no check mark, indicating Resident #47 has not received [MEDICAL TREATMENT] while a resident. During an interview in the MDS Coordinator's office on 7/10/13 at 10:45 AM, the MDS Coordinator was asked if [MEDICAL TREATMENT] should have been checked on the 60 day MDS. The MDS Coordinator stated, Yes. 4. Medical record review for Resident #66 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the (Named) Medical Group Physician's History and Physical dated 5/25/13 documented, .The patient is nonresponsive . Metastatic squamous cell [MEDICAL CONDITION] versus secondary [MEDICAL CONDITION], terminal likely in next 3- (to) 15 days . prognosis is terminal and the family is very much aware . Review of the admission MDS assessment with an assessment reference date of 6/4/13 in section J1400 was coded as a 0, indicating the resident does not have a condition or chronic disease that may result in a life expectancy of less than 6 months. During an interview in the MDS office on 7/10/13 at 8:50 AM, the MDS Coordinator was questioned concerning the terminal prognosis not documented on the 6/4/13 MDS. The MDS Coordinator confirmed the MDS should have documented as a terminal condition. The MDS Coordinator stated, I did not see in the orders as a terminal prognosis . but it was documented in this record . so should have been documented in the MDS .	2017-03-01