cms_AZ: 65

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.

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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
65 HAVEN OF SCOTTSDALE 35059 3293 NORTH DRINKWATER BOULEVARD SCOTTSDALE AZ 85251 2019-01-25 609 D 0 1 NNTV11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, facility documentation and policy and procedures, the facility failed to report an incident of neglect involving one resident (#8) to the State Agency and to Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The physician and responsible party were notified. However, the State Agency and APS were not notified of the incident of neglect within two hours. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated that staff members have been educated that they have to call the State Agency, along with other agencies within two hours of becoming aware of the incident. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. Review of the facility's Abuse policy revealed that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. 2020-09-01