cms_AL: 30

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
30 EASTVIEW REHABILITATION & HEALTHCARE CENTER 15014 7755 FOURTH AVENUE SOUTH BIRMINGHAM AL 35206 2018-01-25 656 D 0 1 I9JH11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and a review of a facility policy titled Care Plans the facility failed to ensure a care plan was developed for fall prevention on resident identifier (RI) #285. This deficient practice affected one of 18 sampled residents whose Care Plans (CP) were reviewed. Findings Include: A review of a facility policy titled Care Plans with a revised date of 09/2009 documented the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing and mental/psychosocial needs . PR[NAME]ESS: I. Entry Record a) . assessment must be completed on every admission . no later that the entry date Plus 14 calendar days . II. a) The comprehensive assessment is completed no later that 14 days of admission . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 8:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was observed to be blank. The surveyor asked for a copy of the Fall Risk Assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed Fall Risk Assessment which was hand signed and dated 01/25/2018 (no time was documented). RI #285's care plan (CP) was reviewed and no fall CP was found. On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. EI #2 was asked if the Fall Risk Assessment had been completed on admission. EI #2 said, no and this was the first Fall Risk Assessment done on RI #285. EI #2 was asked if completed in the computer why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a fall CP for RI #285. EI #2 said, no. RI #285's 12/28/17 MDS documented RI #285 required two person assist with transfers. EI #2 was asked did the MDS address if RI #285 was at risk for falls. EI#2 said, no it did not. EI #2 was asked was fall CP put in place after RI #285 fell on [DATE]. EI #2 said, no. EI #2 was asked should RI #285 been CP for falls. EI #2 said, yes. 2020-09-01