cms_AL: 6

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
6 COOSA VALLEY HEALTHCARE CENTER 15010 260 WEST WALNUT STREET SYLACAUGA AL 35150 2017-04-06 278 D 0 1 0F3P11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #2's height was coded on RI #2's 2/25/16, Initial Minimum Data Set (MDS) assessment, 2) RI #4's height and [MEDICAL TREATMENT] status was coded on RI #4's 7/22/16, Significant Change MDS assessment, and 3) RI #5's catheter was coded on RI #5's 10/21/16, Annual MDS assessment. These deficient practices affected RI # 2, RI #4 and RI #5, three of 15 residents whose MDS assessments were reviewed. Findings Include: 1) RI #2 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Admission Assessment, dated 2/15/16, revealed RI #2 had an admission height of 64 inches. A review of RI #2's Initial MDS assessment with an Assessment Reference Date (ARD) of 2/25/16, revealed RI #2's height was not captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI (Employee Identifier) #8, the MDS Coordinator. The surveyor asked EI #8 should there be a weight and height on the MDS. EI #8 replied, Yes. That is asked on all of them. The surveyor asked EI #8 was RI #2's height coded on RI #2's Admission MDS assessment dated [DATE]. EI #8 said RI #2's height was not on the MDS. EI #8 said the area had 0's and she did not know why. The surveyor asked EI #8 should RI #2's height be on the MDS. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 was RI #2's 2/25/16 MDS assessment an accurate assessment. EI #8 said no, it would not be accurate without the height being on it. 2) RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #4's [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, no date, revealed RI #4 started [MEDICAL TREATMENT] 8/2014. A review of RI #4's Significant Change MDS assessment with an ARD of 7/22/16, revealed RI #4's height nor [MEDICAL TREATMENT] status was captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 was RI #4's height recorded on RI #4's Significant Change MDS dated [DATE]. EI #8 said no, there were 0's on the MDS. The surveyor asked EI #8 should the height be recorded. EI #8 replied, Yes Ma'am, it should be recorded. The surveyor asked EI #8 was RI #4 on [MEDICAL TREATMENT]. EI #8 said yes. EI #8 said RI #4 had been on [MEDICAL TREATMENT] since 2014. The surveyor asked EI #8 should RI #4, being on [MEDICAL TREATMENT], have captured on the 7/22/16 MDS. EI #8 said yes. The surveyor asked EI #8 did she see where the [MEDICAL TREATMENT] status captured on the MDS. EI #8 said she did not. The surveyor asked EI #8 was this MDS assessment an accurate assessment for RI #4. EI #8 replied, no, not with the [MEDICAL TREATMENT] not being on the MDS. 3) RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's most recent annual MDS with an ARD of 10/21/2016, revealed RI #5's Foley catheter status was not captured during this assessment period. The Foley was placed on 8/22/16, and should have captured on the 10/21/16 MDS. On 4/16/17 at 4:10 p.m., the surveyor and EI # 8 had a discussion on when RI #5's Foley catheter was placed. It was agreed from reviewing the resident's chart that the catheter was placed on 8/22/16. The MDS dated [DATE] was reviewed. In section H, Bladder & (and) Bowel, Field H0100, [NAME] Indwelling catheter was coded, 0, On 4/16/17 at 4:25 p.m., an interview was conducted with EI #8. EI #8 was asked who was responsible for coding the MDS. EI #8 replied, she was. EI # 8 was asked was RI #5's 10/21/16 MDS coded correctly in regards to the catheter. EI #8 replied, no ma'am. EI # 8 was asked why the catheter was not checked on 10/21/16 in Section H0100. EI #8 replied, an error, an oversight. EI #8 was asked when should it be coded if a person was using a catheter. EI #8 replied, on the assessment that was due. EI #8 was asked why should a catheter be coded if a resident was using a catheter. EI #8 replied, it tells you they have a catheter and it was important to know that. EI #8 was asked why was it important to code correctly on the MDS. EI #8 replied, the MDS gives you a picture of the resident. EI #8 stated when looking at the MDS, you should be able to know everything about the resident. 2020-09-01