cms_AK: 31

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

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
31 KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE 25010 3100 TONGASS AVENUE KETCHIKAN AK 99901 2019-08-23 690 D 0 1 0OWF11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 resident's (#8) catheter, of 4 sampled residents with an indwelling catheter, was secured to prevent free movement of tubing and discomfort. This failed practice placed the resident at risk for discomfort, pain, trauma and further catheter complications. Findings: Urinary Catheter or UTI Resident #8 Review of the most recent quarterly Minimal Data Set (MDS-federally required nursing assessment), dated 6/18/19, revealed Resident #8 was coded as having an indwelling catheter. During an observation on 8/20/19 at 2:00 pm revealed Certified Nurse Assistant (CNA) #3 was providing activities of daily living cares to Resident #8. While the CNA was dressing the Resident, the catheter tubing was noted to be passed through a securing device adhered to Resident #8's left inner thigh. The clamp on the securing device ([MEDICATION NAME] Foley Stabilization Device) was over the tan-colored catheter tubing approximately 4 inches above the bifurcation section (area that contained the balloon control port and the connection to the clear drainage tubing). As a result, the tan-colored tube was observed to freely slide up and down through the securing device. During an interview on 8/20/19 at 2:00 pm, CNA #3 was asked if the catheter tube was properly secured to the Resident's left inner thigh. CNA #3 stated the securing device should have held the tubing in place. During a subsequent observation on 8/20/19 at 2:10 pm, CNA #3 proceeded to secure the tubing in the securing device but was unable to do so successfully. During the CNA's attempt to secure the catheter tubing, Resident #8 yelled out in discomfort and stated it was uncomfortable when the CNA was pulling on the catheter tubing. During an observation on 8/21/19 at 1:09 pm, Licensed Nurse (LN) #4 assessed the securing device for Resident #8's catheter. LN #4 stated the catheter tubing was not properly held in place by the securing device. Next, LN #4 attempted to secure the tubing but was unable to successfully place the tubing in the device to prevent movement. During the observation, Resident #8 was grimacing and stated it was uncomfortable while LN #4 was attempting to secure the tubing. During an interview on 8/21/19 at 1:11 pm, LN #4 stated the tubing was not properly secured to prevent movement of the catheter tubing. LN #4 further stated the catheter tubing and the securing device were not compatible because the securing device clamp was too small for the catheter tubing. During an interview on 8/21/19 at 1:16 pm, LN #1 stated he/she was able to secure the catheter tubing to the inner thigh securing device by placing only the balloon control port inside the securing device's clamp. Review of the undated [MEDICATION NAME] Foley Stabilization Device Information Guide, revealed the bifurcation area of the catheter should be placed in the clamp. Specifically, both the balloon control port and the area immediately above the junction of the tan-colored tubing and the clear draining tubing should be secured under the clamp. The information guide did not indicate to only secure the balloon control port. Further review revealed the securing device was designed to reduce the risk of pulling on the catheter which could have caused pain and trauma. In addition, the information guide stated the securing device was to provide a comfortable, secure and hygienic placement of the catheter away from areas of the body that could have led to bacteria contaminating the surface of the catheter. Review on 8/21/19 at 1:20 pm of the facility's CAUTI (Catheter Associated Urinary Tract Infection) Prevention Bundle Book, dated 8/20/19 revealed the day and night shift nurses documented Resident #8's securement device was properly used and the tubing was free from kinks and dependent loops. Further review revealed the day nurse on 8/21/19 also documented the securement device was properly used and the tubing was free from kinks and dependent loops. 2020-09-01